COLUMBIA  UBRARIES  OFFSITE 


HX641 17588 
RC76.3  .Ew1  Ca'diac  outlines  for 


RECAP 


Carhiac  Outlines 


EWART 


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Digitized  by  the  Internet  Arciiive 

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WORKS    BY    THE    SAME    AUTHOR. 


The  Bronchi  and  Pulmonary  Blood-Vessels.  Their 
Anatomy  and  Nomenclature  ;  with  a  criticism  of  Professor 
Aeby's  Views  on  the  Bronchial  Tree  of  Mammalia  and  of 
Man.     With  20  illustrations 

How  to  Feel  the  Pulse  and  What  to  Feel  in  It.— 
Practical  Hints  for  Beginners.     With  12  illustrations.      $1.50 

IN   PREPARATION. 

Pulmonary  Outlines  for  Clinical  Clerks  and  Practi- 
tioners. 

Heart-Studies,  Chiefly  Clinical : 

I. — The   Pulse    under    the   Sphygmograph   and   under 
the   Finger. 


CARDIAC  OUTLINES 

FOR    CLINICAL   CLERKS 
AND  PRACTITIONERS 


AND 


FIRST  PRINCIPLES  IN  THE  PHYSICAL  EXAMINATION 
OF  THE  HEART  FOR  THE  BEGINNER 


BY 


WILLIAM  EWART,  M.D.  Cantab.,  F.R.C.P. 

PHYSICIAN   TO   ST.    GEORGe's    HOSPITAL,  CLINICAL    LECTURER    AND     TEACHER    OF     PRACTICAL 
MEDICINE    m    THE    MEDICAL   SCHOOL,    PHYSICIAN   TO    THE    BELGRAVE    HOSPITAL    FOR 
CHILDREN,    ADDITIONAL    EXAMINER     IN     1891    FOR   THE    THIRD    M.B.    OF   THE 
UNIVERSITY    OF     CAMBRIDGE,     LATE     ASSISTANT     PHYSICIAN     AND 
PATHOLOGIST    TO    THE    BROMPTON     HOSPITAL     FOR     CON- 
SUMPTION    AND     DISEASES     OF     THE     CHEST 


WITH    SIXTY-TWO    ILLUSTRATIONS 


G.  P.  PUTNAM'S    SONS 

NEW   YORK  LONDON 

27   WEST  TWENTY-THIRD    STREET  24    BEDFORD    STREET,    STRAND 

®:i^E  llnithcrbothcr  ^rcss 
1 892 


Copyright,  1892 

BY 

WILLIAM    EWART 

Entered  at  Staiiovers'   Hall,  London 
By  William  Ewart 
(All  rights  reserved) 


Electrotyped,  Printed,  and  Bound  by 

Ube  1Rnicl;erbocf!cr  press,  IRew  igorft 

G.  P.  Putnam's  Sons 


DEDICATED    TO 

TIMOTHY    HOLMES 

CONSULTINf,    SURGEON    TO    ST.    GEORGe's    HOSPITAL 

by  his  grateful  pupil 

The   Author 


PREFACE. 

The  publication  of  this  collection  of  Cardiac  Outlines  was  undertaken 
with  a  threefold  object  :  to  help  the  beginner  through  his  first  difficulties, 
to  encourage  the  clinical  clerk  in  the  cultivation  of  the  graphic  method  as 
a  means  to  thoroughness  and  accuracy,  and  to  place  at  the  disposal  of  the 
practitioner  an  easy  method  of  adequately  recording  important  clinical 
observations.  This  little  book  does  not  profess  to  be  a  treatise  on  cardiac 
diseases.  With  the  exception  of  short  and  incidental  pathological  sketches 
it  is  entirely  devoted  to  the  study  of  physical  examination  under  healthy 
and  morbid  conditions.  My  aim  has  been  to  provide  the  reader  with  a 
method  which  he  may  find  equal  to  the  requirements  of  cardiac  study,  and 
which  may  help  him  onwards  farther  than  I  am  yet  competent  to  lead. 

It  would  have  been  impossible  to  have  set  forth  the  method  as  a  whole 
without  including  some  details  not  strictly  elementary.  At  the  same  time 
the  needs  of  the  junior  student  have  been  steadily  considered,  both  in' the 
beginning  which  has  been  made  rudimentary,  and  in  the  gradual  progression 
to  more  advanced  subjects. 

I  am  under  a  pleasing  obligation  to  my  nephew,  Mr.  P.  de  Vaumas,  for 
valuable  assistance  in  the  production  of  several  of  the  illustrations. 


WM.  EWART, 

33  Curzon  St.,  May  Fair, 

London,  W. 


New^  York,  March,  1892. 


CONTENTS. 


PAGE 

Introductory  Remarks , .  = i 

Elementary  Clinical  Outline  of    the  Chest 4 

The  Imaginary  Lines  of  Reference 6 

PART  I. 

THE    DESCRIPTIVE  OR    ANATOMICAL  SERIES   OF    OUTLINES. 

The  Thorax 9 

The  Liver,  Stomach,  and  Spleen  in  their  Mutual  Relation  and  in  their 

Relation  to  the  Thorax 12 

The   Hepatic    Boundaries 14 

The  Praecordium  and  the  Prsevascular  Area 16 

The  Pericardial  Sac  and   Membrane 18 

The  Boundaries  of  the  Floor  of  the  Pericardium 20 

The  Inclination  of  the  Pericardial  Floor 22 

The  Shape  and  Position  of  the  Heart  and  its  Relation  to  the  Liver  and 

Ribs 24 

The  Cardiac  Apex  and  Base 26 

The  Right  Ventricle  and  Auricle 28 

The  Septum  Ventriculorum,  the  Cardiac  Axis,  and  the  Cardiac  Base   ...  30 

The  Left  Ventricle 32 

The  Left  Auricle 34 

The  Position  of  the  Great  Vessels  in  Connection  with  the  Heart 35 

vii 


viii  Contents. 

PART  11 

THE    DERMOGRAPHIC    METHOD    AND    THE    CONSTRUCTIVE    SERIES    OF 

OUTLINES. 

PAGE 

How  to  Determine  the  Apex  Spot  and  the  Left  Ventricular  Basic  Line, 

or  Line  of  the  Appendices 40 

The  Site  of  the  Pulmonary  Artery 44 

How  to  Localise  the  Auricular  Appendices,  the  Pulmonary  Artery,   the 

Aorta,  and  the  Semilunar  Valves 46 

Method  for  Tracing  the  Lateral  Lines  of  the  Cardiac  Diagram 48 

The  Heart's  Outline  Completed 52 

PART   HI. 

THE   PRACTICAL   METHODS    OF    INSPECTION    AND    PALPATION. 

Inspection  of  the  Anterior  Surface  of  the  Thorax 56 

Palpation  of  the  Anterior  Surface   of  the   Thorax 57 

Palpation  of  the   Prsecordium  for  Cardiac   Impulses 59 

Palpation  for  Abnormal  Impulses  and  Thrills 60 

PART  IV. 

cardiac  percussion  and  the  "percussion"  series  of  outlines 
(normal  and  pathological). 

Remarks  on  Cardiac  Percussion 63 

vSansom's  Pleximeter 66 

The  Cardiac  Surface  Left  Uncovered  by  Lung 69 

The  Area  of  Absolute  Cardiac  Dulness 70 

First  Step  in  the  Examination  of  the  Heart  by  Percussion  :   How  to  De- 
termine the  Absolute  Hepatic  Dulness 72 

Second  Step  :   How  to  Determine  the  Absolute  Cardiac  Dulness 74 

Third  Step  :   How  to  Determine  the  Partial  Dulness  of  the  Liver 78 

Fourth  Step  :   How  to   Determine  the  Partial  Cardiac   Dulness  in  the 

Right  Half  of  the  Chest , 80 


Contents.  ix 

PAGE 

Fifth  Step  :   How  to  Determine  the  Partial  Cardiac  Dulness  in  the  Left 

Half  of  the  Chest 82 

Sixth  Step  :   How  to  Determine  the  Prasvascular  Dulness 84 

Seventh  and  Final  Step  :  The  Hepatic  and  the  Suprahepatic  Lines  as 

Obtained  by  Percussion 86 

Cardiac  Percussion  in  Abnormal  Conditions 92 

Cardiac    Hypertrophy  :    Its   Varieties    and    its    Influence    on    Cardiac 

Dulness 93 

Cardiac     Dilatation  :     Its    Varieties    and     its    Influence    on    Cardiac 

Dulness 94 

The   Encroachment  on   Thoracic   Space    Due    to    Combined     General 

Hypertrophy  and  Dilatation  of  the  Heart 96 

The  Changes  in  the  Relations  of  Parts  in  Pericardial  Effusion  ;  and  the 

Diagnosis  of  Effusion  by  Percussion 98 

The  Heart  in  Pericardial  Dropsy 100 

PART  V. 

CARDIAC    AUSCULTATION  IN    THE    NORMAL    SUBJECT   AND    IN    PATHOLOGICAL 

CONDITIONS. 

The  Heart  Valves  Seen  from  Below 104 

The  Valves  Seen  from  Above 105 

The  Sites  of  the  Valves  Projected  to  the  Anterior  Surface  of  the  Chest 

— The  Left  Third  Cartilage  as  a  Landmark 106 

The  Topography  of  the  Semilunar  Valves 108 

The  Topography  of  the  Auriculo- Ventricular  Valves no 

Auscultation  Series  : 

The  Principles  and  the  Method  of  Cardiac  Auscultation 112 

The  Heart-Sounds — Suggested  Code  of  Symbols  for  the  Normal  Heart- 
Sounds  and  for  their  Pathological  Variations 114 

Where  to  Listen  for  the  Normal  Heart-Sounds 120 

Code  of  Symbols  for  the  Notation  of  Valvular  Murmurs 123 

List  of  the  Cardiac  Valvular  Murmurs 124 

The  Sites  for  the  Auscultation  of  the  Cardiac  Murmurs 125 

The  Areas  of  Conduction  of  Murmurs 126 


X  Contents. 

PAGE 

The  Site  and  Area  of   Conduction  of  the  Systolic  Pulmonary  Murmur, 

and  of  the  Hsemic  Murmur 128 

The  Site  and  Area  of  Conduction  of  the  Tricuspid  Regurgitant  Murmur.    132 

The  Site  and  Area  of  Conduction  of  the  Onward  Aortic  Murmur 134 

The  Site  and  Area  of  Conduction  of  the  Regurgitant  Aortic  Murmur.  .    136 
The  Site  and  Area  of  Conduction  of  the  Regurgitant  Mitral  Murmur.  .    140 
The  Heart  Viewed  from  the  Left  Side  to   Illustrate  the  Mode  of  Con- 
duction of  the  Regurgitant  Mitral  Murmur 142 

The   Site  and  Area    of  Conduction  of  the  Mitral  Auricular-Systolic, 

Prse-Systolic,  or  Diastolic  Murmur 144 

The  Auscultatory  Signs  of  Cardiac  Hypertrophy 148 

The  Auscultatory  Signs  of  Cardiac  Dilatation 149 

Aortic  Aneurysm.      The  Structures  Liable  to  Implication  in  Aneurysm 

of  the  Ascending  Aorta  and  of  the  Arch 150 

Pericarditis.      A  Brief  Summary  of  its  Varieties  and   Typical   Signs  : 

I.    Local    or  Limited   Pericarditis.     2.    General  Pericarditis 152 

Dry  or  Fibrinous  Pericarditis.  Friction  Sounds  and  Friction  Mur- 
murs .  {a)  External  Pericardial  Friction  Sounds  ;  {b^  In- 
ternal Pericardial  Friction  Sounds 153,  154 

Pericarditis  with  Effusion 156 

Practical  Points  in  the  Auscultatory  Diagnosis  of  Pericarditis  : 

1 .  Diagnosis  between  Endocardial  and  Exocardial  Murmurs 158 

2.  Diagnosis  between  Internal   and  External   Pericardial    Friction 

Sounds 1 59 

PART  VI. 

PRACTICAL     ILLUSTRATIONS     OF     THE     METHOD     OF    USING     DIAGRAMS    AND 
SYMBOLS  FOR    THE    RECORD    OF    PHYSICAL   EXAMINATIONS    OF    THE 

HEART  : 

The  Value  of  Negative  Notes 160 

The  Prepared  Clinical  Outline  and  its  Uses 162 


INTRODUCTORY   REMARKS. 

ON  THE  VALUE  OF  ANATOMICAL  PRECISION  AND  ON  THE 

USE  OF  THE  GRAPHIC  METHOD  IN  THE  CLINICAL 

STUDY  OF  THE  HEART. 

Most  teachers  will  probably  agree  with  the  author  in  tracing  to  an  im- 
perfect appreciation  of  anatomical  facts  a  large  share  of  the  trouble  usually 
experienced  in  the  earlier  stages  of  clinical  study  ;  and  in  regarding  the 
graphic  method  as  the  surest  means  of  safeguarding  the  beginner  against 
the  evils  of  an  inadequate  anatomical  training. 

Medical  anatomy,  so  far  as  it  relates  to  the  heart,  presents  no  intrinsic 
difficulties.  It  commonly  happens,  however,  that  the  student  is  already 
cut  off  from  the  opportunities  of  dissecting  when  a  knowledge  of  visceral 
anatomy  becomes  indispensable  to  him.  Too  often  he  is  apt  to  regard 
medical  anatomy  as  distinct  from  anatomy  in  the  strict  sense.  Any  lack  of 
anatomical  accuracy  in  the  clinical  manuals  placed  in  his  hands  confirms 
this  impression  ;  and  his  anatomical  notions  and  his  clinical  studies  are  kept 
asunder  at  the  time  when  their  combination  would  have  been  of  most  use. 

Clinical  anatomy,  or  the  anatomy  of  the  living  organism,  is  in  reality  not 
less  precise  than  the  anatomy  of  the  dead  body  ;  on  the  contrary,  it  exacts 
a  knowledge  of  additional  detail.  We  should  be  imperfectly  guided  in  our 
clinical  work  and  in  our  visceral  surgery  were  we  to  trust  alone  to  the  rela- 
tions of  parts  such  as  they  are  learned  in  the  dissecting-room.  The  main 
anatomical  facts  remain  as  a  basis,  but  on  this  groundwork  a  knowledge  of 
the  configuration  of  the  living  viscera  has  to  be  elaborated.  This  is  the 
special  office  of  percussion  and  of  auscultation.  In  the  hands  of  the 
expert  these  methods  may  be  said  to  take  up  and  to  complete  the  work 
of  dissection. 

On  the  other  hand  it  is  of  obvious  advantage  to  the  inexperienced  per- 
cussor  that  he  should  be  guided  by  broad  anatomical  facts.  Beginners 
would  make  slow  progress  in  percussion  and  auscultation  without  the  help 

I 


2  CARDIAC   OUTLINES. 

of  anatomy  ;  and  in  percussion  of  the  heart,  which  is  probably  more  diffi- 
cult and  more  important  than  that  of  most  other  organs,  this  assistance  is 
more  needful  than  elsewhere. 

In  the  arrangement  of  the  work  the  author  has  been  guided  by  a  belief 
that  anatomical  knowledge  should  be  made  the  starting-point,  whilst  it  is 
also  the  goal  of  the  clinical  methods  of  percussion  and  auscultation.  We 
should  learn  to  percuss  with  the  help  of  anatomical  data  ;  whilst  the  highest 
office  of  percussion  is  to  enable  us  to  trace  the  individual  anatomy  of  each 
chest  with  an  accuracy  not  attainable  by  any  other  means. 

The  graphic  method  affords  us  welcome  aid  in  both  stages  of  this  scheme. 
The  anatomical  facts  essential  for  a  clinical  study  of  the  heart  can  be  most 
quickly  taught,  and  with  greatest  advantage,  by  means  of  a  graduated  scries 
of  diagrams,  which  the  student  should  learn  to  trace  for  himself.  This  prac- 
tice will  confer  not  only  a  knowledge  of  normal  anatomy,  but  a  facility  for 
drawing  diagrams  of  abnormal  hearts. 

Independently  of  the  educational  purpose  in  view,  a  special  need  for 
some  anatomical  detail  arose  in  these  pages  in  connection  with  some  of  the 
principles  of  cardiac  percussion,  which  will  probably  be  regarded  as  novel, 
and  might,  in  the  absence  of  anatomical  proof,  have  been  deemed  arbitrary. 

For  the  Outlines  themselves  no  artistic  value  can  be  claimed.  They 
are  simply  diagrams,  and  in  many  respects  imperfect  ;  but  special  care  has 
been  taken  to  avoid  any  glaring  departure  from  anatomical  principles  on 
all  essential  points.  Exception  might  be  taken  to  the  dimensions  and  to 
the  shape  of  the  thorax.  The  preference  given  to  the  broad  type  of 
chest  was  guided  by  a  practical  purpose,  and  the  somewhat  unusually  large 
size  will  probably  be  found  a  convenience  in  note-taking.  Again  the 
manifest  unreality  of  a  simultaneous  tracing  of  the  ribs  and  of  the  heart  has 
its  justification  in  the  attempt  to  facilitate  a  localisation  of  the  heart  and  of 
its  sounds.  Diagrams  constructed  on  this  plan  may  be  difficult  to  decipher 
at  first,  but  if  any  one  of  them  be  understood  the  others  will  not  puzzle  the 
reader. 

THE  DIVISION  OF  THE  WORK. 

The  Outlines  are  divided  into  the  following  groups  : 

(i)  A  descriptive  or  anatomical  series  gives  a  sketch  of  the  thorax,  of  the 
liver,  of  the  heart,  and  of  the  pericardium. 


-        ,  CARDIAC  OUTLINES,  3 

(2)  A  "  constructive  "  series  illustrates  the  way  in  which  a  diagram  of  the 

heart  can  be  correctly  traced  on  the  chest  of  the  living  or  of  the 
dead  subject. 

(3)  A  few  pages  are  devoted  to  the  methods  of  physical  examination  and 

to  inspection  and  palpation  in  health  and  in  disease. 

(4)  Percussion  of  the  heart  under  normal  and  under  pathological  condi- 

tions is  dealt  with  in  the  next  series  of  Outlines. 

(5)  The  section  devoted  to  cardiac  auscultation  is  preceded  by  remarks  on 

the  normal  and  pathological  heart  sounds,  and  by  codes  of  symbols 
for  use  in  describing  abnormal  heart  sounds  and  cardiac  murmurs 
by  means  of  the  graphic  method. 

(6)  Lastly,  examples  are  given  showing  the  manner  of  using  the  diagrams 

and  symbols  for  clinical  records. 


CARDIAC  OUTLINES, 


ELEMENTARY    CLINICAL    OUTLINE    OF    THE 

CHEST. 

A  simple  diagram  of  the  front  of  the  chest,   useful  for  clinical  purposes, 
can  be  constructed  with  six  lines  and  a  long  vertical  arrow. 
The  head  of  the  arrow  stands  for  the  xiphoid  cartilage  ; 
The  notch  at  the  other  end  for  the  episternal  notch. 
The  lines  represent : 

The  two  clavicles. 

The  two  costal  arches,  and 

The  lateral  outline  of  the  thorax. — 

The  nipples,  and 

The  timbilicus 
complete  the  essential  parts  of  the  diagram  ;    the   dotted  lines  not  being 
essential. 

This  rough  diagram  can  be  rapidly  sketched,  requires  no  knowledge  of 
drawing,  and  will  therefore  enable  any  observer  to  add  to  his  notes  a  fairly 
accurate  graphic  record  of  the  physical  signs  discovered  in  the  chest. 


FIG.  I. 


I 


The  lines    represent  :  the  clavicles,   the  sternum,   the  costal  arch,   the 
nipples,  and  the  umbilicus  (M). 


CARDIAC  OUTLINES. 


THE  IMAGINARY  LINES  OF  REFERENCE. 

The  following  lines  only  are  used  as  lines  of  reference  in  connection  with 
the  heart : 

The  middle  line, 

The  vertical  nipple  line, 

The  parasternal  line. 

THE  MIDDLE   LINE. 

The  thorax  is  very  often  far  from  symmetrical  ;  and  in  order  to  judge  of 
the  extent  of  the  asymmetry,  and  for  other  reasons,  we  require  a  middle  line 
which  shall  be  true. 

How  to  Trace  a  True  Line  on  the  Chest. — Stretch  a  cord  between 
the  two  points  selected.  Along  this  a  pencil  or  marking  chalk  may  be 
drawn.  Better  still  is  the  plan  suggested  to  me  by  a  valued  pupil,  Mr. 
L.  Moysey.  The  cord  or  thread,  having  been  previously  made  damp  with  a 
little  ink,  is  lifted  off  the  skin  between  the  nails  of  two  fingers  and  allowed 
to  fly  back  like  the  string  of  a  bow,  the  result  being  a  perfectly  straight 
and  distinct  ink-mark. 

How  to  Determine  the  Middle  Line. — We  select  with  this  view  the 
umbilicus,  which  remains  almost  always  strictly  median  in  position,  and  the 
middle  of  the  episternal  notch.  This  point  also  is  generally  in  the  middle 
line,  so  long  as  no  great  thoracic  deformity  exists,  and  that  the  clavicles  are 
of  even  length  (neither  fractured  nor  unusually  bent).  By  uniting  these  two 
points  a  line  will  be  obtained  which  very  frequently  will  pass  to  one  side  or 
the  other  of  the  tip  of  the  sternum.  Deviations  of  this  bone,  and  therefore 
of  the  long  axis  of  the  thorax,  being  much  less  considerable  above  than 
below,  the  episternal  notch  is  usually  a  reliable  guide.* 

*  In  special  cases  of  deformity  it  may  be  necessary  to  strike  a  line  between  the  middle 
line  of  the  face,  and  the  umbilicus  (or  even  the  symphysis  pubis),  whilst  the  patient  is 
standing  perfectly  straight. 


Fia  11. 


M — The  umbilicus.   MC — The  mid-clavicular,  or  nipple,  line.   PS — The 
parasternal  line. 


8  CARDIAC  OUTLINES. 

THE  VERTICAL  NIPPLE  LINE. 

The  nipples  being  very  liable  to  vary  in  site,  and  in  the  adult  female  being 
moreover  mobile,  are  not  perfect  landmarks,  although  constantly  used  as 
such.  A  vertical  line  drawn  through  the  middle  of  the  clavicle  coincides  with 
the  nipple  line,  when  this  is  normally  situated.  The  mid-clavicular  line  has 
the  advantage  of  starting  from  a  fixed  spot,  and  is  therefore  to  be  preferred  ; 
it  is  indicated  in  the  diagram  under  the  letters  MC. 

THE  PARASTERNAL  LINE. 

This  line  is  of  great  practical  importance.  It  lies  half  way  between  the 
other  two.  The  parasternal  line,  as  well  as  the  mid-clavicular,  being  paral- 
lel to  the  middle  line,  can  be  accurately  drawn  with  the  help  of  one  instead 
of   two  landmarks. 


PART  I. 

THE   DESCRIPTIVE  OR  ANATOMICAL  SERIES 

OF  OUTLINES. 

The  Outlines  belonging  to  this  series  are  intended  to  illustrate  points  in 
the  anatomy  of  the  heart  and  of  its  surroundings,  possessing  clinical  interest 
or  importance. 

THE  THORAX. 

Notice  in  this  Outline  : 

(i)  The  width  of  the  manubrium  ; 

(2)  The  rigid  sternal  attachment  of  the  first  rib  ; 

(3)  The  overlapping  of  the  clavicle,  leaving  no  space  above  the  first  rib  ; 

(4)  The  transverse  ridges  intersecting  the  sternum  ; 

(5)  The  upper  line  of  junction  (double  dotted)  between  the  manubrium 

and  the  gladiolus.  This  junction  remains  cartilaginous  up  to  a 
consideraljle  age  or  permanently,  and  capable  of  bending  at  an 
angle,  which  is  then  known  as  the  Angulus  Ludovici. 

ANGULUS  TUDOVICT. 

This  is  a  rather  frequent  deformity  dependent  upon  the  cartilaginous  na- 
ture of  the  junction  just  described.  If,  under  the  forces  at  work,  the  sternum 
be  bent  forwards  (Angulus  Ludovici),  the  chest  space  will  be  enlarged  by 
so  much.  If  it  be  bent  backwards  (other  form  of  Angulus  Ludovici),  chest 
space  will  be  lost. 

Angular  deformity  of  any  other  part  of  the  sternum  is  seldom  seen.      The 


10  CARDIAC  OUTLINES. 

xiphoid  joint,  however,  is  very  pliable,   and  the  xiphoid  cartilage  subject  to 
various  displacements. 

THE  COSTAL  CARTILAGES. 

(i)  The  1st  chondrocostal  junction  lies  external  to  the  oblique  line  join- 
ing the  others. 

(2)  The  4th  chondrocostal   junction  lies    about  an    inch  internal    to    the 

nipple. 

(3)  The  1st  and  2d  cartilages  slant  upwards  from  the  sternum  ;  the  3d  is 

usually  horizontal  ;    the   others  leave    the   sternum   at    an    angle, 
downwards. 

(4)  All,  except  the  1st,  are  connected  with  the  sternum  by  articulations. 

(5)  The    6th    and    7th   cartilages    articulate   with   each    other   so   as   to 

strengthen  the  costal  arch. 

(6)  Tlie  two  yih  cartilages  form   the  costal  arch,  in  conjunction  with  the 

end  of  the  gladiolus  ;    they  receive  the  insertion  of  the  8th  car- 
tilages. 

(7)  The  8th  cartilages  receive  the  insertion  of  the  gth  ;  and  the  gth  that  of 

the  loth. 

(8)  The  nth  cartilages  may  be   felt  at  the  sides  ;  they  are  free  from  any 

connection  with  the  costal  arch.     The   12th  cartilages  cannot  be 
seen  or  felt  from  the  ffont. 


¥IG.  III. 


The  direction  of  the  mid-clavicular  line  (MC)  is  indicated  by  the  arrows. 
N.  B. —  T/ie  loivest  sternal  segmetit  is  too  long  in  the  diagram. 


II 


12  CARDIAC  OUTLINES, 


THE    LIVER,   STOMACH,  AND    SPLEEN    IN    THEIR 
MUTUAL  RELATION  AND  IN  THEIR  RELA- 
TION TO  THE  THORAX. 

The  diaphragm  is  not  shewn  in  the  Outline  ;  nevertheless  its  position 
may  be  readily  gathered,  its  convex  surface  following  the  line  SH  and  the 
direction  of  the  same  line  continued  on  the  left  side  down  to  S  ;  whilst  the 
line  of  attachment  of  the  membrane  coincides  in  the  main  with  that  of  the 
costal  arch. 

The  stomach,  although  not  normally  in  immediate  contact  with  the 
heart,  is  separated  from  it  only  by  a  small  thickness  of  liver. 

The  spleen  is  seen  to  be  far  removed  from  the  region  X  of  the  cardiac 
beat. 

THE    LIVER   IN    SITU. 

A  knowledge  of  the  position  of  the  liver  is  essential  to  our  description 
of  the  heart,  since  the  liver  may  be  said  to  form  the  heart's  basis  of 
support. 

The  following  points  will  be  noticed  in  the  diagram  : 

(i)  The  general  resemblance  of  the  outline  of  the  liver  (/«  j-?V«)  to  that 
of  a  cocked  hat,  one  extremity  pointing  straight  to  the  left,  the 
other  extremity  straight  down  ; 

(2)  Its  almost  complete  inclusion  within  the  thorax,  with  the  exception  of 

(3)  A  small  portion  left  unprotected  by  cartilage  or  bone  at  the  epi- 

gastrium. 

(4)  It  occupies  the  right  two  thirds  of  the  dome  of  the  diaphragm,  the 

left  third  of  which  shelters  the  stomach  and  spleen. 

(5)  Its   thin   and  sharp    inferior  and  anterior  edge    (IH    in    the   figure) 

is  in  contact  with  the  anterior  thoracic  wall  along  the  line  of 
the  costal  arch  ;  and  the  same  contact  is  kept  up  by  the  anterior 
zone  of  the  convex  surface  of  the  liver,  for  some  small  distance 
upwards. 


FIG.  IV. 


G — The  semilunar  line  of  gastric  resonance.  S — The  spleen.  SH — 
The  upper  boundary  of  the  liver  within  the  thorax  (suprahepatic  line).  IH 
— The  lower  border  of  the  liver.  H — The  upper  hepatic  boundary  in  direct 
contact  with  the  anterior  chest-wall  (hepatic  line).  X — The  left  extremity 
of  the  liver. 

N.  B. —  The  left  lobe  of  the  liver  should  have  extended  slightly  beyond  the 
left  nipple  line  in  the  diagram, 

13 


14  CARDIAC  OUTLINES. 

(6)  The  line  along  which  the  contact  between  the  diaphragm  covering  the 

liver  and  the  anterior  thoracic  wall  ceases  is,  for  convenience, 
termed  in  these  pages  the  Hepatic  Line  (H  in  the  figure). 

(7)  Above  this  level  the   convex   surface   still    rises   considerably  ;   but 

it  recedes  as  it  rises. 

(8)  The  inferior  surface,  owing  to  the  way  in  which  the  bulk  of  the  liver 

finds  room  in  the  depth  of  the  thorax,  reveals  in  a  front  view 
little  of  the  great  thickness  of  the  posterior  hepatic  border  ;  on  the 
contrary,  this  surface,  which  is  slightly  concave,  slants  upwards  and 
backwards,  as  viewed  from  below. 

(10)  The  right  extremity  is  thick. 

(11)  The  left  extremity  is  very  thin  ;   it  extends  farther  than  depicted 

in  the  Outline,  and  at  least  as  far  as  the  mid-clavicular  line. 

N.  B. — The  hepatic  line  of  thoracic  contact,  H,  has  a  very 
slight  fall  towards  the  left,  which  is  not  made  sufficiently  evident 
in  the  diagram. 


THE    HEPATIC    BOUNDARIES. 


These  all  vary  during  deep  respiration.  During  tranquil  respiration  the 
displacements  are  moderate,  and  the  average  levels  would  be  as  follows  : 

The  Inferior  Hepatic  Line,  IH,  nearly  coincides  with  the  right  costal 
arch  as  far  as  the  tip  of  the  8th  rib  ;  thence  crossing  the  epigastrium  as 
a  tangent  to  the  tip  of  the  xiphoid  (this  relation  varies  much)  it  rises  to  the 
left  extremity  (X)  of  the  organ. 

The  Hepatic  Line,  H,  passes  nearly  horizontally  through  the  sterno- 
xiphoid  joint,  having  a  slight  inclination  downwards  towards  the  left.  In 
the  right  hypochondrium  it  is  convex  to  the  right,  and  follows  a  downward 
course  between  the  6th  and  loth  chondrocostal  junctions. 

The  Supra-hepatic  Line,  SH,  is  almost  horizontal,  at  a  level  just  below 
that  of  the  right  5th  chondrocostal  junction  ;  in  its  course  both  to  the  left 
and  downwards  it  is  almost  parallel  with  the  hepatic  line  just  described. 
Its  left  extremity  is  slightly  curved  downwards. 


CARD  FA  C  OUTLINES.  I  5 

The  Fundus  of  the  Gall-bladder  lies  to  the  inner  side  of  the  tip  of  the 
right  9th  rib. 

The  boundary  between  the  right  and  the  left  lobes  (at  IH)  is  situated 
nearly  half  way  between  the  tip  of  the  gth  rib  and  that  of  the  xiphoid 
cartilage. 

N.  B.  The  hepatic  boundaries  will  be  again  alluded  to  in  Part  IV.,  and 
will  form  the  subject  of  systematic  study.  Reference  will  also  be  made 
to  the  changes  in  level  to  which  these  boundaries  are  liable  as  a  result  of 
the  respiratory  variations  in  the  capacity  and  in  the  contents  of  the  chest. 


1 6  CARDIAC  OUTLINES. 


THE   PR^CORDIUM    AND    THE    PR^VASCULAR 

AREA. 

The  Prcecordiuni,  or  praecordial  region,  is,  in  the  broader  sense,  that  part 
of  the  anterior  thoracic  surface  which  covers  the  heart  (see  also  Outline  VI). 
It  includes  : 

(i)  The  sternum  from  the  upper  level  of  the  3d  cartilages  to  the 
xiphoid  ; 

(2)  The  left  4th  and  5th  cartilages  from  rib  to  sternum,  and  the  4th 
interspace  ; 

(3)  The  inner  third  of  the  left  3d  and  6th  cartilages,   and  the  sternal 

extremity  of  the  7th  ;  also  the  greater  part  of  the  3d  and  of  the 
5th  intercartilaginous  spaces  ; 

(4)  The  inner  third  of  the  right  4th,  5th,  and  6th  cartilages,  and  of  the 

3d,  4th,  and  5th  intercartilaginous  spaces. 

It  is  best  not  to  apply  the  term  preecordium  to  the  more  limited  area  to 
be  described  in  Part  IV.  as  the  area  of  absolute  dulness,  over  which  the 
cardiac  surface  is  covered  only  by  the  thoracic  wall. 

The  Prtcvascular  Area  is  of  much  smaller  extent.  It  is  continued 
upwards  from  the  proecordium,  as  far  as  the  lower  clavicular  level,  and 
corresponds  to  the  upper  segment  of  the  gladiolus,  to  the  manubrium,  and 
to  the  inner  third  of  the  1st  and  2d  cartilages  and  of  their  interspaces. 


FIG.  V. 


The  surface  above  the  interrupted  line  is  the  prsevascular  area.  The 
surface  below  the  same  line  is  the  praecordial  area. 

N.  B  —  The  ' '  base  of  the  heart  "  does  not  strictly  correspond  with  the  line 
given  in  this  diagram  {cf.  page  26,  and  Outline  XL). 

17 


1 8  CARDIAC  OUTLINES. 

THE    PERICARDIAL    SAC    AND    MEMBRANE. 

No  cavity  (in  the  sense  of  free  space)  exists  in  the  pericardium  in  health  : 
besides  the  heart,  the  pericardium  contains  only  a  few  drops  of  fluid. 

The  Sac  is  capacious  in  comparison  with  the  size  of  the  heart,  and  fits  the 
latter  loosely  (especially  at  the  sides). 

The  Alembrane  is  described  as  possessing  a  visceral  2in^  2i  parietal  layer. 
The  visceral  layer  covers  the  entire  free  cardiac  surface,   and  accom- 
panies the  great  vessels  for  a  short  distance.     Being  reflected  from  them, 
it  is  continued  into  the  parietal  layer. 

The  parietal  layer  forms  the  serous  sac.  It  is  loose  at  the  sides  only, 
being  elsewhere  adherent  to  various  structures  ;  the  most  important  of 
these  are  : 

The  oesophagus. 

The  great  vessels,  and 

The  central  tendon  of  the  diaphragm. 

It  is  adherent  to  : 

The  thymus  and  the  sternum  in  front. 

The  oesophagus  and  tracheal  bifurcation  behind, 

The  great  vessels  and  the  deep  fascia  of  the  neck  above,  and 

The  central  part  of  the  diaphragm  below. 

The  hea't  therefore  possesses  some  freedom  of  vertical  movement  and 
considerable  freedom  of  lateral  movement ;  but  its  antero-posterior  range 
of  movement  is  limited. 

THE   PLEURO-PERICARDIUM. 

This  is  a  convenient  anatomical  and  clinical  name  for  the  loose  lateral 
portion  of  the  parietal  layer,  which  is  intimately  adherent  to,  and  forms 
one  membrane  with,  the  corresponding  loose  portion  of  the  parietal  layer 
of  the  pleura.  This  double  membrane  has  thus  a  pleural  face  and  a  peri- 
cardial (or  mediastinal)  face,  and  is  a  mobile  partition  between  the  peri- 
cardial cavity  and  the  pleural  cavity.  It  is  attached  to  the  root  of  the  lung 
^nd  encloses  the  phrenic  nerve. 


FIG.  VI. 


A— The  aorta.  B— The  gall-bladder.  D— Diaphragm.  CE— The 
oesophagus.  J— The  left  hepatic  lobe,  in  vertical  section.  G-  The  fundus 
of  the  stomach,  in  section.  H— The  anterior  hepatic  level  (hepatic  line). 
SH— The  superior  hepatic  level  (suprahepatic  line).  Pc— The  pericardial 
membrane, 

19 


20  CARDIAC  OUTLINES, 


THE     BOUNDARIES     OF     THE     FLOOR     OF     THE 

PERICARDIUM. 

(i)  It  is  seen  that  the  left  half  of  the  chest  contains  more  of  this  surface 
than  the  right  (almost  in  the  proportion  of  f  to  \,  or  at  least  of  f  to  |^),  and 
that  the  portion  included  in  the  right  half  broadens  from  front  to  back. 

(2)  The  surface  of  the  floor  of  the  pericardium  is  polygonal  or  very 
irregularly  circular,  with  some  resemblance  to  a  lozenge  :  it  includes  the 
surface  of  the  middle  or  anterior  division  of  the  Centrum  tendineum,  and  of 
some  of  the  anterior  muscular  bundles  of  the  diaphragm,  more  particularly 
on  the  left  side, 

(3)  It  occupies  the  greater  portion  of  the  interval  between  the  base  of 
the  xiphoid  appendix  and  the  oesophagus. 

(4)  The  right  border  is  oblique  outwards  and  backwards,  forming  an 
anterior  angle  with  the  end  of  the  sternum,  and  a  posterior  angle  at  the 
orifice  of  the  vena  cava.  The  posterior  border  extends  from  the  latter  to  the 
left,  in  front  of  the  oesophagus.  The  left  border  is  convex  outwards  and 
almost  semicircular  between  the  oesophagus  and  the  left  7th  chondrosternal 
joint,  with  increased  convexity  at  the  apex  site,  X.  The  anterior  border  is 
very  short,  nearly  corresponding  to  the  line  of  the  sterno-xiphoid  joint. 

(5)  The  outline  of  the  floor  of  the  pericardium  might  therefore  be 
described  os, polygonal  rather  than  circtdar,  but  without  any  sharp  angles. 

(6)  Its  longest  diameter  extending  from  left  front  to  right  back. 

(7)  The  outline  further  displays  the  situation  of  the  orifice  of  the  Vena 
Cava,  presently  to  be  described,  and  of  the  phrenic  nerves  and  accompanying 
vessels. 


FIG.  VII. 


M — Middle  line  of  body,  and  tip  of  sternum,  attached  to  which  are  the 
costal  cartilages,  A — Aorta  encircled  by  crura  of  diaphragm.  CE — Oesoph- 
agus and  pneumogastric  nerves.  IC — Inferior  vena  cava.  X — Extreme 
left  boundary  line  (line  of  cardiac  apex).  C — Extreme  right  boundary  line 
(line  of  vena  cava). 

N.  B. —  The  interrupted  lines  have  refereitce  to  the  ligaments  of  the  liver. 


21 


22  CARDTAC  OUTLIJ^ES. 


THE  INCLINATION  OF  THE  PERICARDIAL  FLOOR. 

This  Outline  displays  several  of  the  points  described  in  Outline  VII.  But 
in  addition  it  gives  some  idea  of  the  inclination  of  the  floor  of  the  pericar- 
dium.    This  is  inclined  on  the  horizontal  in  two  directions  : 

(i)  A  very  slight  inclination  from  the  right  to  the  left,  downwards  ; 

(2)  A  very  marked  inclination  from  back  to  front,  downwards. 

The  resulting  inclination  might  be  readily  demonstrated  by  tilting  a 
small  oblong  four-legged  table.  If  the  two  legs  on  one  of  the  long  sides 
(that  farthest  from  the  observer)  be  made  longer  than  the  other  two,  so  that 
the  table  slopes  towards  the  observer  ;  and  if  the  two  (now  uneven)  legs  on 
the  observer's  left  be  raised  to  an  equal  but  very  small  extent,  by  placing 
under  them  a  thick  board,  the  lowest  spot  of  the  whole  surface  will  be  at 
the  anterior  corner  facing  the  observer's  right.  This  is  precisely  the  slope 
of  the  pericardial  floor. 

On  the  contrary,  the  highest  spot  of  the  table's  surface  would  obviously  be 
the  right  posterior  corner  (observer's  left).  On  referring  to  the  two  diagrams 
of  the  pericardial  floor  it  will  be  seen  that  this  spot  is  occupied  by  the 
orifice  of  the  Inferior  Vena  Cava.  It  is  important  therefore  to  remember 
that  the  orifice  of  the  Inferior  Vena  Cava  into  the  right  auricle  is 

(i)    The  highest  and  (2)  the  extreme  right  spot 
at  the  heart's  lower  surface  ;  it  being  understood  that  the  heart  is  in  direct 
contact  with  this  part  of  the  floor  of  the  pericardium. 

On  the  other  hand,  to  the  heart's  apex  is  allotted 

(i)  The  lowermost  and  (2)  the  extreme  left  position. 

The  way  in  which  the  serous  layer  of  the  membrane  is  reflected  from  the 
side  and  floor  of  the  pericardium  to  the  left  surface  of  the  vein  at  its  ter- 
mination is  shown  in  Outline  VII.  Both  Outlines  show  that  the  parietal 
layer,  on  the  contrary,  is  applied  and  adherent  to  the  right  surface  of  the 
vein.  By  this  means  the  corresponding  part  of  the  right  auricle  is  bound 
down  to  this  spot  of  the  pericardial  floor  ;  and  this  is  the  only  attachment 
which  the  lower  surface  of  the  heart  suffers. 

The  Outline  also  shews  the  CEsophagus  in  its  close  relation  to  the  poste- 
rior wall  of  the  pericardium  ;  and  the  Inferior  Vena  Cava  receiving  the 
capacious  Hepatic  Veins. 


FIG.   VIII. 


CE — The  oesophagus  (behind  the  pericardium).  IC — The  inferior  vena 
cava,  terminating  just  within  the  pericardium.  H — The  anterior  hepatic 
level,  and  the  anterior  attachment  of  the  pericardium.  SH  (horizontal 
portion  of  SH) — The  posterior  hepatic  level,  and  the  posterior  attachment  of 
the  pericardium. 

~~  23 


^4  CARDIAC  OUTLINES. 


THE  SHAPE  AND  POSITION  OF  THE  HEART  AND 
ITS  RELATION  TO  THE  LIVER  AND  RIBS. 

The   anterior    surface    of   the    heart    is   here    exposed    to   view.     This 
displays  : 

(i)  The  entire  width  and  height  of  the  Right  Ventricle  ; 

(2)  A  small  portion  of  the  Left  Ventricle  ; 

(3)  The  anterior  surface  of  the  Right  Auricle  ; 

(4)  A  portion  of  the  Left  Auricular  Appendix  ; 

(5)  The  origin    of    the   Aorta,   Pulmonary  Artery,    and    Superior  Vena 

Cava  ; 

(6)  (The  outline  of  the  Left  Auricle  would  not  be  seen  from  the  front, 

in  the  normal  subject  ;) 

(7)  The  Apex  of  the  Right  Ventricle  and  that  of  the  Left ; 

(8)  The   "  Base  "  of  the  heart  : 

(g)  The  obliquity  of  the  heart's  longitudinal  axis  downwards,  forwards, 
and  to  the  left  ; 

(10)  The  anterior  position  of  the  Right  cavities  and  the  deep  position  of 

the  Left  cavities  ; 

(11)  The  lower  level  of  the  Right  cavities  ; 

(12)  The  higher  level  of  the  Left  cavities  (which  indirectly  results  from 

the  convexity  of  the  upper  surface  of  the  liver)  ;   and 

(13)  The  relatively  high  level  of  the  orifice  of  the  Inferior  Vena  Cava, 

due  to  the  same  cause  ; 

(14)  The  relations  of  the  anterior  cardiac  surface  to  the  thorax,  to  the 

nipple,  to  the  liver,*and  to  the  stomach  and  spleen. 


FIG.  IX. 


The  letters  refer  to  the  same  structures  as  in  previous  Outlines. 


25 


26  CARDIAC   OUTLINES. 

THE    CARDIAC   APEX    AND    BASE. 
THE    APEX. 

The  heart's  apex  is  not  a  mere  point  but  a  rounded  surface,  formed 
chiefly  by  the  left  ventricle.  On  its  left  aspect  it  is  covered  by  lung  ;  but 
during  systole  it  moves  slightly  from  under  cover  towards  the  right.  That 
portion  of  the  cardiac  surface  which  is  felt  beating,  and  is  commonly  known 
as  the  "  apex-beat,"  is  the  right  aspect  of  the  apex  ;  it  belongs  in  part  to 
the  right  ventricular  wall. 

THE    POSITION   OF    THE   CARDIAC   APEX. 

The  normal  position  of  the  heart  cannot  be  described  in  terms  of 
measurement,  since  the  size  of  individuals  varies  ;  but  it  is  correct  to 
localize  the  average  site  of  the  apex  in  the  5th  left  interspace,  a  little 
internal  to  the  mid-clavicular  line,  and  nearer  to  the  6th  than  to  the 
5th  rib. 

THE    POSITION    OF    THE   BASE    OF   THE    HEART. 

The  present  Outline,  viewed  apart  from  any  preconceived  notions,  would 
suggest  that  the  heart  resembles  a  cone  or  a  pyramid.  A  line  XS  (see  Out- 
line XL)  passing  through  the  cardiac  apex,  X,  and  through  the  top  of  the 
right  shoulder,  might  be  regarded  as  the  axis  of  the  heart  as  well  as  the 
axis  of  the  Septum  Ventriculorum  :  and  the  base  of  the  heart  would  be  per- 
pendicular to  this  line. 

The  origin  of  the  Aorta  and  that  of  the  Pulmonary  Artery  being  situated 
at  the  upper  extremity  of  the  line  XS,  are  correctly  described  as  belonging  to 
the  cardiac  base.  At  the  same  time  the  reader  will  presently  gather  from 
Outline  XI.  that,  strictly  speaking,  the  plane  of  the  base  of  the  heart  would  be 
included  between  the  planes  LL'  (of  the  base  of  the  left  ventricle)  and  RR' 
(of  the  base  of  the  right  ventricle),  and  would  therefore  be  represented  in 
the  diagram  by  a  line  much  more  oblique  than  that  which  runs  through  the 
orifices  of  the  Aorta  and  of  the  Pulmonary  Artery. 

Clinically  the  term  "base"  is  applied  somewhat  indefinitely  to  the 
region  including  the  sternal  end  of  the  right  and  left  3d  cartilages  and  of 


CARDIAC  OUTLINES,  27 

the  2d  Interspaces.  It  would  probably  be  variously  defined  by  different 
authorities.  In  this  uncertainty  the  student  should  bear  in  mind  the  fol- 
lowing points  : 

(1)  The  plane  of  the  cardiac  base  is  not  correctly  represented  by  a  hori- 

zontal line  such  as  is  shown,  for  instance,  in  Fig.  VI. 

(2)  Its  extent  is  not  correctly  represented  by  the  distance  which  intervenes 

between  the  "aortic"  or  right  2d  interspace,  and  the  "pulmo- 
nary "  or  left  2d  interspace. 

(3)  On  the  contrary,  the  plane  of  the  cardiac  base  has  an  oblique  direction 

and  it  diverges  fro?n  the  horizontal  line  joining  the  2d  interspaces  ; 

(4)  For,  whilst  the  left  2d  interspace  corresponds  to  the  origin  of  the 

Pulmonary  Artery,  the  right  2d  interspace  does  not  correspond  to 
the  origin  of  the  Aorta. 

(5)  Therefore,  although  the  second  sound  is  listened  for  at  the  right 

2d  interspace,  this  is  not  the  site  of  its  production  ; — and  simi- 
larly, although  in  clinical  language  we  may  refer  to  murmurs 
audible  there  as  "  basic"  murmurs,  this  should  not  lead  us  to  sup- 
pose that  the  2d  interspace  coincides  in  position  with  the  plane  of 
the  base  of  the  heart. 


28  CARDIAC  OUTLINES. 


THE  RIGHT  VENTRICLE. 

The  anterior  wall  of  the  Right  Ventricle  and  of  the  Pulmonary  Artery 
has  been  removed,  exposing  to  view  their  cavities.* 

The  position  of  the  Tricuspid  Valve  and  of  the  Semilunar  Valves  is 
roughly  indicated.     Specially  to  be  noticed  are  : 

(i)  The  Conus  Arteriosus,  seen  in  vertical  section,  as  it  crosses  the  root 
of  the  Aorta  which  lies  behind  it  ; 

(2)  The  Septum  between  the  ventricles,  S,  bulging  towards  the  right ; 

(3)  The  Lower  or  Right  flap  of  the  Tricuspid  Valve  ; 

(4)  The  Posterior  Pulmonary  Semilunar  flap,  PP,  immediately  covering 

the  origin  of  the  Aorta  (the  other  two  flaps  are  anterior). 

(5)  Notice  that  the   anterior   surface   (see   Outline    IX.)  being  roughly 

triangular,  and  the  inferior  or  diaphragmatic  and  the  septal  sur- 
faces being  also  triangular,  the  cavity  of  the  Right  Ventricle  repre- 
sents a  pyramidal  space. 

THE  RIGHT  AURICLE. 

The  Right  Auricle  occupies  the  space  between  the  right  border  of  the 
sternum  and  the  extreme  right  cardiac  boundary  close  to  the  parasternal 
line.  Some  idea  of  its  shape  and  size  may  be  formed  by  remembering  that 
it  extends  backwards  as  far  as  the  orifice  of  the  Inferior  Vena  Cava  ;  and 
that  its  highest  point  anteriorly  is  formed  by  the  tip  of  the  Right  auricular 
appendix,  behind  the  middle  of  the  sternum,  at  the  level  of  the  3d  rib. 

*  In  this  and  the  three  following  Outlines  the  tracing  of  the  ribs  has  been  interrupted 
over  the  prsecordium,  to  avoid  confusion. 


FIG.  X. 


SC — The  superior  vena  cava.  IC — The  inferior  vena  cara.  I — The 
infundibulum  laid  open  from  the  front,  together  with  the  right  ventricle. 
P — The  pulmonary  artery  ;  behind  which  the  shaded  surface  of  the  left 
auricle.  PP — The  posterior  pulmonary  valve  flap  ;  the  two  anterior  flaps 
have  been  removed  with  the  front  wall  of  the  vessel. 

29 


30  CARDIAC  OUTLINES, 


THE    SEPTUM    VENTRICULORUM,    THE    CARDIAC 
AXIS,  AND  THE  CARDIAC   BASE. 

In  the  erect  posture  the  Septum  forms  an  almost  vertical  partition,  XS, 
between  the  two  ventricles.  Its  course  is  not  absolutely  straight,  but 
slightly  curved  with  convexity  towards  the  right  ventricle.  Its  plane  is 
neither  strictly  sagittal  nor  transverse  ;  but  it  passes  obliquely  from  the  apex, 
backwards  and  to  the  right,  and  slightly  upwards,  towards  the  spine.  The 
following  points  can  be  made  out  in  the  Outlin;e  : 

(i)  With  its  lower  border  the  Septum  rests  upon  the  diaphragm. 

(2)  This  lower  border,  or  foot,  is  therefore  not  horizontal,  but,  like  the 
upper  surface  of  the  liver,  it  slopes  upwards  and  backwards,  nearly  parallel 
to  the  line  XS. 

(3)  The  anterior  or  upper  border  is  superficial,  and  corresponds  to  the  ante- 
rior interventricular  groove.  (See  Outlines  IX,  and  X. — In  the  present 
Outline  the  upper  part  of  the  septum  is  supposed  to  have  been  cut  away.) 

(4)  At  its  anterior  extremity  the  Septum  forms  the  apex  of  the  heart  ;  it 
possesses  here  no  appreciable  height.  From  this  point  backwards  it  quickly 
becomes  taller,  acquiring  its  greatest  height  halfway  between  the  apex  and 
the  base  of  the  ventricles. 

(5)  It  assists  in  the  formation  of  the  Conus  Arteriosus,  or  Infundibulum, 
of  which  it  may  be  regarded  as  the  left  and  inferior  wall. 


FIG.  XI. 


XS — Axis  of  the  heart,  passing  through  the  septum  ;  the  septum  having 
been  partly  removed,  a  view  is  obtained  of  the  left  as  well  as  of  the  right 
ventricular  cavity.  LL' — Line  passing  through  the  plane  of  the  base  of  the 
left  ventricle.  RR' — Line  passing  through  the  plane  of  the  base  of  the  right 
ventricle. 

N.  B. —  The  plane  of  the  base  of  the  heart  as  a  zuhole  would  fall  between 
these  two  planes, 

31 


32  CARDIAC  OUTLINES, 


THE    LEFT    VENTRICLE. 

This  Outline  is  intended  to  show  the  relation  which  the  cavity  of  the 
Left  Ventricle  bears  to  that  of  the  Right  Ventricle,  and  to  the  Septum. 
The  Septum,  exposed  by  removing  the  anterior  wall  of  the  right  ventricle 
as  in  the  previous  Outline,  is  supposed  to  have  been  partly  cut  away,  and 
with  it  also  a  portion  of  the  anterior  wall  of  the  left  ventricle. 

The  same  incisions  carried  upwards  have  excised  (between  letters  P 
and  I)  that  portion  of  the  conus  arteriosus  and  pulmonary  artery  which  lies 
in  front  of  the  origin  of  the  aorta.  A  view  is  thus  obtained  (to  the  left  of 
the  Septum,  S)  of  the  interior  of  the  left  ventricle,  and  of  the  beginning  of 
the  aorta. 

With  the  help  of  these  explanations,  the  reader  will  easily  recognise  the 
following  structures  : 

(i)  The  Aorta,  A,  laid  open,  showing  the  Semilunar  Valves,  namely,  the 
Right  posterior,  part  of  the  Left  posterior,  and  part  of  the 
Anterior  flap. 

(2)  The  Pulmonary  Artery,  P,  divided  and  partly  removed. 

(3)  The  Conus  Arteriosus,  I,  partly  removed. 

(4)  The  foot  of  the   Septum,  S,  across  which  lie  some   of  the   divided 

chordae  tendinese  of  the  Tricuspid  valve. 

(5)  The  Mitral  valve,  M,  connected  by  means  of  its  chordae  tendineas  with 

the  Musculi  Papillares  below. 

(6)  The  left  lateral  situation  of  the  Septum  causes  the  left  ventricle  to  be 

entirely  contained  within  the  left  half  of  the  chest. 

(7)  A  fortiori  the  Mitral  valve,  which  occupies  the  left  posterior   and 

upper  corner  of  the  ventricle,  is  well  to  the  left  of  the  middle  line, 
and  of  the  sternum. 

(8)  The  upper  part  of  the  Septum  being  separated  from  the  surface  by  the 

thickness  of  the  Conus  Arteriosus  which  lies  in  front  of  it,  we 
realize  the  still  deeper  position  taken  by  the  Left  ventricular 
cavity. 

(9)  It  follows  that  the  Aortic  valve  is  situated  rather  deeply  behind  the 

left  side  of  the  sternum  ;  and  that 


FIG.  XIL 


S — The  foot  of  the  septum,  to  the  right  and  left  of  which  are  seen  the 
Ventricles.^  M— The  anterior  mitral  flap.  T— The  right  lower  tricuspid 
flap.  I — The  conus  arteriosus  divided  and  partly  removed.  P— The  pul- 
monary artery  ;  behind  P  the  left  auricle  is  seen  in  outline.  A— The  aorta 
cut  open,  showing  the  right  posterior  aortic  flap  and  part  of  the  other  flaps. 

33 


34  CARDIAC  OUTLINES. 


(lo)  The  Mitral  valve  belongs  to  a  yet  more  remote  plane,  being  indeed 

nearer  to  the  spine  than  to  the  sternum. 
(ii)  As  a  whole  the  left  ventricle  occupies  a  higher  level  in  the  thorax  than 

the  right  ventricle  ;  and 
(12)  The  Mitral  valve  is  situated   high   up,   as  well   as   far  back  in  the 

ventricle. 

THE   LEFT  AURICLE. 

The  Left  Auricle  is  strictly  posterior  and  entirely  out  of  sight  in  a  front 
view  of  the  heart,  with  the  exception  of  the  tip  of  the  auricular  appendix 
which  comes  forward  to  the  left  of  the  root  of  the  pulmonary  artery. 

In  order  to  facilitate  for  the  student  an  appreciation  of  its  situation,  the 
auricle  is  brought  "  diagrammatically  "  into  view  ("  anatomically  "  it  would 
be  invisible)  between  the  pulmonary  artery  and  the  aorta,  and  between  the 
aorta  and  the  superior  vena  cava. 

Unlike  the  Right  Auricle  it  does  not  rest  on  the  diaphragm,  but  extends 
rather  higher  than  its  fellow, — in  the  same  way  as  the  left  ventricle  is 
placed  at  a  higher  level  than  the  right. 

It  is  the  hindermost  of  all  the  cavities  of  the  heart,  and  nearly  fills  the 
angle  formed  by  the  two  main  bronchi. 

The  Pulmonary  Veins  are  entirely  out  of  sight. 

The  position  of  the  left  auricular  appendix  affords  demonstration  of  the 
left-sided  position  of  the  mitral  orifice  ;  for  in  any  heart  the  appendix  lies 
above,  and  in  close  proximity  to  this  orifice,  and  may  therefore  be  taken  as 
a  guide  to  its  situation. 


CARDIAC  OUTLINES.  35 


THE  POSITION  OF  THE  GREAT  VESSELS  IN  CON- 
NECTION  WITH  THE  HEART. 

In  addition  to  structures  previously  described,  this  Outline  displays  the 
origin  and  early  course  of  the  great  vessels  issuing  from  the  heart,  with  the 
exception  of  the  pulmonary  veins. 

THE   AORTA. 

(i)  The  Aorta  is  entirely  hidden  at  its  origin  by  the  anteriorly  placed 
Conus  Arteriosus  and  Pulmonary  Artery,  and  slightly  by  the  Right 
Auricle. 

(2)  Within  the  pericardium  it  is  exposed  to  view  in  its  Ascending  portion 

which  is  in  right  lateral  and  in  anterior  contact  with  the  Superior 
Vena  Cava. 

(3)  Behind  the  right  second  interspace,  whilst  still  within  the  pericardium, 

it  becomes  yet  more  superficial,  being  only  covered  by  a  thin  edge 
of  lung,  and  its  curvature  is  already  pronounced.  The  part 
projecting  beyond  the  right  border  of  the  sternum  is,  however,  very 
small. 

(4)  Still  smaller  is  the  portion  covered  by  the  right  2d  cartilage. 

(5)  Above  this  level  the  ascending  portion  of  the  arch  lies  entirely  behind 

the  manubrium,  giving  off  the  Innominate  Artery  on  the  right, 
and  the  Left  Carotid  and  Subclavian  on  the  left.  At  their  origin 
these  vessels  are  in  close  relation  respectively  with  the  right  and 
with  the  left  1st  chondrosternal  junctions. 

(6)  The  termination  of  the  Transverse  portion  and  the  beginning  of  the 

Descending  portion  are  seen  in  foreshortening  in  the  left  second 
interspace. 

(7)  The  part  of  the  Aorta  just  described  lies  almost  entirely  behind  the 

upper  sternum. 

(8)  It  will  be  noticed  that,  whilst  the  first  part  of  the  vessel  moves  for- 

wards and  to  the  right,  as  far  as  the  right  2d  space,  the  second 
part  recedes  from  the  surface  upwards  and  to  the  left. 


36  CARDIAC  OUTLINES. 

(9)  The  highest  level  reached  by  the  Arch  is  usually  that  of  the  lower 
border  of  the  ist  cartilage.  But  there  is  much  individual  variety 
in  this  respect. 

THE   SUPERIOR  VENA  CAVA. 

(i)  The  course  of  this  vessel,  SC,  is  for  the  greater  part  intrapericardial, 
usually  as  far  as  a  point  just  below  its  bifurcation  into  the  Innominate 
Veins. 

(2)  Its  orifice  into  the  right  auricle,  not  shewn  in  the  diagram,  is  nearly 
in  the  same  vertical  line  as  that  of  the  Inferior  Vena  Cava  (from  which  it  is 
separated  by  the  Eustachian  Valve).  It  is  deeply  situated,  but  not  so 
deeply  as  the  orifice  of  the  Inferior  Vena  Cava. 

(3)  Emerging  from  behind  the  base  of  the  auricular  appendix,  the  first 
portion  of  the  Superior  Vena  Cava  is  somewhat  overlapped  by  the  ascending 
part  of  the  Aorta  in  front. 

(4)  But,  at  the  level  of  the  2d  rib,  whilst  the  Artery  begins  strongly  to 
recede,  the  Vein  advances,  and,  casting  off  its  pericardial  covering,  divides 
into  the  vertical  Right  Innominate  Vein  and  the  horizontal  Left  Innominate 
Vein.  The  subsequent  bifurcation  of  each  of  these  two  veins  occurs  behind 
the  corresponding  sternoclavicular  joints. 

THE  INFERIOR  VENA  CAVA. 

(i)  The  orifice  of  the  Inferior  Vena  Cava,  IC,  into  the  right  auricle  is 
shewn  in  dotted  outline.  It  lies  far  back,  behind  the  thickness  of  the  liver, 
and  is  raised,  as  it  were,  by  the  vertical  thickness  of  the  organ.  It  is,  as 
stated  above,  the  highest  spot  in  that  part  of  the  diaphragmatic  surface 
which  is  included  within  the  pericardium  ;  and  it  lies  higher  therefore  than 
any  other  spot  belonging  to  the  inferior  surface  of  the  right  auricle  or 
ventricle. 

(2)  The  level  of  the  orifice,  in  the  parasternal  line,  corresponds  to  that  of 
the  5th  cartilage. 

(3)  The  portion  of  the  Vena  Cava  which  projects  above  the  diaphragm, 
purposely  depicted  here  as  a  short  vessel,  is  hardly  recognisable  as  an  inde- 
pendent structure,  but  immediately  broadens  out  into  the  auricle. 

(4)  The  posterior  wall  of  the  vessel  is,  however,  more  readily  recognised 
than  the  anterior,  as  distinct  from  the  auricle. 


FIG.    XIII. 


SC— The  superior  vena  cava.  Ao — The  aorta.  IV— The  left  innomi- 
nate vein  lying  in  front  of  the  origin,  from  the  arch,  of  the  three  great 
1_^      TT'     The  jugular  veins.    AA' — The  subclavian  arteries.    W — The 


vessels.    JJ 

subclavian  veins.     CC 
ing  the  hepatic  veins. 


-The  carotids.     IC — The  inferior  vena  cava  receiv- 


37 


38  CARDIAC  OUTLINES. 


THE  PULMONARY  ARTERY. 

This  vessel  is  remarkable  for  : 
(i)  Its  shortness, 

(2)  Its  almost  vertical  direction, 

(3)  Its  superficial  position, 

(4)  Its  contact  with  both  Auricular  Appendices, 

(5)  Its  funnel-shaped  Conus  Arteriosus. 
Moreover  for  : 

(6)  The  angle  formed  by  its  axis  with  that  of  the  Aorta  behind  ; 

(7)  Its  strongly  lateral  position — (it  lies  for  the  greater  extent  outside  the 

left  border  of  the  sternum  in  the  2d  interspace)  ;  and 

(8)  Its  bifurcation  behind  the  left  2d  chondrosternal  joint, 

(9)  The  Right  Pulmonary  Artery  passes  nearly  horizontally  to  the  right, 

beneath  the  Arch  of  the  Aorta. 
(10)  The  Left  Pulmonary  Artery  continues  its  upward  course,  with  slight 
obliquity  towards  the  left,  and  with  increasing  obliquity  backwards. 
It  finally  arches  downwards  into  the  left  lung,  under  cover,  from 
above,  of  the  Aortic  Arch. 


PART  II. 

THE    DERMOGRAPHIC    METHOD    AND    THE    CON- 
STRUCTIVE   SERIES    OF    OUTLINES. 

The  following  Outlines  are  termed  "  constructive"  because  intended  to 
shew  how  the  normal  cardiac  tracing  may  be  built  up  on  data  derived  from 
the  thoracic  skeleton,  or  from  superficial  landmarks,  with  the  help  of  the 
dermographic  method,  or  method  of  surface  markings. 

The  first  tracings  to  be  practised  by  the  beginner  are  the  tho7'acic  lines  of 
reference.  Each  student  should  make  out  by  inspection  and  palpation  and 
draw  on  the  chest  of  a  suitable  subject  the  mid-clavicular,  the  parasternal, 
and  the  hepatic  lines.     Let  this  be  done  at  least  once  thoroughly. 

Tracings  of  the  cardiac  boundaries  may  be  obtained  in  two  ways  : 

(i)  By  the  use  of  definite  landmarks  based  on  a  knowledge  of  the  rela- 
tions of  the  heart  to  the  thoracic  parietes  ;  and 

(2)  More  directly  by  means  of  percussion  in  each  individual  case. 

The  latter  method,  the  only  one  available  in  pathological  conditions, 
is  essentially  a  clinical  method,  implying  considerable  skill  and  experience. 
Special  attention  will  be  given  to  it  in  Part  IV. 

On  the  other  hand,  the  constructive  method  is  applicable  only  to  the 
normal  subject  ;  and  its  uses  are  chiefly  educational.  It  is  a  means  of 
impressing  the  cardiac  boundaries  on  the  memory,  and  a  useful  introduc- 
tion to  the  more  difficult  stages  in  cardiac  study. 

This  part  of  the  subject  has  been  treated  more  fully  than  is  necessary  in 
the  case  of  the  junior  student ;  but  the  reader  will  easily  select  among  the 
Outlines  those  best  suited  to  his  own  requirements. 

39 


40  CARDIAC  OUTLINES. 

In  the  construction  of  the  Cardiac  Outlines  the  following  sequence  has 
been  adopted  : 

(i)  Determination  of  the  position  of  the  apex  of  the  left  ventricle. 

(2)  Determination  of  the  base  of  the  left  ventricle. 

(3)  Determination  of  the  left  lateral  cardiac  boundary. 

(4)  Determination  of  the  right  lateral  cardiac  boundary. 

(5)  Localisation  of  the  great  vessels. 

The  landmarks  used  for  this  purpose  are,  as  already  stated,  either  super- 
ficial (cutaneous)  or  deep  (thoracic  or  costal).  Two  constructive  methods 
are  thus  at  our  disposal:  the  "  superficial,"  more  rapid  but  rather  more 
sketchy  method  ;  and  the  "  deep,"  more  laborious,  but  probably  more 
exact  one.      Both  will  be  described  in  connection  with  the  Outlines, 

HOW  TO  DETERMINE  THE  APEX  SPOT  AND  THE 

LEFT  VENTRICULAR  BASIC  LINE,  OR  LINE 

OF  THE  APPENDICES. 

(i)  Find  the  base  of  the  Xiphoid,  or  the  Infrasternal  angle  (formed  by 
the  7th  cartilages,  which  nearly  meet  at  the  extremity  of  the 
gladiolus). 

(2)  Through  this  draw  a  horizontal  line  HH'  (the  Hepatic  line)  ; 

(3)  And  through  the  right  mamilla  draw  the  nipple  line,  which  will  meet 

the  hepatic  line  at  H. 

(4)  As  a  tangent  to  the  areola  of  the  nipple  draw  a  vertical  line,   the 

Inner  Areolar  line.     This  will  meet  the  hepatic  line  at  Ar. 

The  apex  of  the  ventricle  will  very  closely  correspond  to  the  apex 
of  the  right  angle  thus  formed. 

(5)  Draw  the  horizontal  line  MS,  half-way  between  the  episternal  notch 

and  the  infrasternal  angle,  and 

(6)  Join  the  point  H  with  the  middle  point  of  the  sternum. 

(7)  The  prolongation  SL,  of  this  line  to  the  left  is  the  line  wanted,  viz., 

the  left  ventricular  basic  line,  or  line  of  the  appendices. 


FIG.  XIV. 


\ 


SC,  SC — Sterno-clavicular  joints.  Ar — Vertical  inner  areolar  line  (the 
position  of  the  cardiac  apex  is  indicated  in  dotted  line).  MM' — Nipples  and 
nipple  lines,  HH' — Hepatic  line.  HL — Line  conducted  through  the 
middle  point  of  the  sternum.  MS — Horizontal  line  dividing  the  sternum 
into  two  equal  parts. 


42  CARDIAC  OUTLINES, 


OTHER  METHOD  FOR  DETERMINING  THE  APEX 

SPOT  AND  THE  LEFT  VENTRICULAR  BASIC 

LINE,  OR  LINE  OF  THE  APPENDICES. 

This  method  dififers  from  the  preceding  in  that  it  relies  upon  the  skeletal 
instead  of  the  superficial  landmarks.  It  requires  as  a  preliminary  that  the 
ribs  be  recognised  and  a  few  of  them  numbered  for  reference. 

Draw,  as  in  the  previous  Outline  : 

(i)  The  hepatic  line. 

(2)  The  left  inner  areolar  line  (this  line  is  seen  to  coincide  exactly  with 

the  5th  chondrocostal  junction — a  valuable  skeletal  landmark  for 
localising  the  cardiac  apex). 

(3)  Find  the  right  5th  and  the  left  2d  chondrocostal  junction  : 

(4)  A  line  drawn  through  these  two  points  will  meet  the  middle  line  at 

MS,  halfway  down  the  sternum  ;    its  prolongation  to  the  left  is 
the  line  sought. 


FIG.    XV. 


Ill — Right  third  costo-chondral  junction.  V — Right  fifth  costo-chon- 
dral  junction.  VI — Right  sixth  cartilage.  MS — Line  dividing  the  sternum 
into  an  upper  and  a  lower  half.  IT — Left  second  costo-chondral  junction. 
IV' — Left  fourth  costo-chondral  junction.  V — Left  fifth  costo-chondral 
junction. 

43 


44  CARDIAC  OUTLINES. 


THE   LEFT  VENTRICULAR  BASIC   LINE,  OR  LINE 

OF    THE  APPENDICES,  AND  THE  SITE 

OF  THE  PULMONARY  ARTERY. 

If  a  line  M'SC,  to  which  we  may  refer  as  the  left  oblique  line,  be  con- 
ducted from  the  inner  side  of  the  left  areola,  to  the  right  sternoclavicular 
joint,  this  will  intersect  at  L  the  line  H  I,  which  was  described  in 
Outline  XIV. 

Divide  the  distance  ML  into  three  equal  parts  ;  and  draw  at  the  points 
of  division  two  lines  of  the  shape  and  length  of  the  small  dotted  lines. 
These  will  represent,  as  is  shown  in  the  following  Outline,  the  sides  of  the 
Pulmonary  Artery. 

The  further  use  of  the  line  M'SC  will  be  given  on  page  48. 


FTG.  XVI. 


M'SC— The  left  oblique  lateral  line  (the  outline  of  the  left  ventricle  is 
indicated  in  dotted  line).  ML— The  line  of  the  auricular  appendices  (t/. 
Fig.  XVII. ).  The  small  dotted  lines  shew  the  position  of  the  pulmonary 
artery.     The  ether  letters  as  in  previous  outlines. 

45 


46  CARDIAC  OUTLINES. 


HOW    TO     LOCALISE     THE    AURICULAR     APPEN- 
DICES, THE  PULMONARY  ARTERY,  THE  AORTA, 
AND    THE    SEMILUNAR   VALVES. 

The  line  ML  enables  trs  to  localise  six  important  structures  : 
(A)  THE  TWO  AURICULAR  APPENDICES. 

The  Outline  of  the  Pulmonary  Artery  is  supposed  to  have  been  drawn  as 
described  over  leaf  ; 

At  its  sides,  and  slightly  overlapping  it,  should  be  drawn  the  apex  of  the 
Right  and  that  of  the  Left  Auricular  Appendix.  The  two  appen- 
dices exactly  face  each  other,  and  they  both  terminate  (AS,  AP) 
on  the  line  ML. 

Each  auricular  appendix  occupies  a  lateral  third  of  the  line  ML.  In 
shape  they  may  be  roughly  depicted  as  triangles,  the  base  of  which 
would  be  perpendicular  to  the  line  ML. 

Further  peculiarities  of  outline  should  be  committed  to  memory. 

It  is  understood  that  this  description  is  purely  diagrammatic.  The  tips 
of  the  auricular  appendices  (especially  that  of  the  left),  may  deviate  from 
the  line  ML,  and  may  differ  slightly  in  length  and  in  direction  from  those 
here  depicted. 

(B)  THE  AORTA  AND  THE  AORTIC  SEMILUNAR  VALVE. 

The  axis  of  the  first  part  of  the  Aorta  is  very  nearly  perpendicular  to  the 
direction  ML,  and  the  vessel  rises,  as  it  were,  partly  from  the  middle  third, 
and  partly  from  the  inner  third  of  that  line. 

The  aortic  orifice  and  semilunar  valve  thus  coincide,  in  their  transverse 

axis,  with  the  line  ML. 
The  anterior  aortic  semilunar  flap  AS  is  dotted  to  signify  that  it  is  situ- 
ated behind  the  pulmonary  artery. 


J 


FIG.   XVII. 


HH' — Hepatic  line.  Ar — Vertical  inner  areolar  line.  L — Left  auricu- 
lar appendix,  facing  which  is  the  right  auricular  appendix.  AP — The  two 
anterior  pulmonary  valve  flaps.  AS — The  anterior  semilunar  flap  of  the 
aortic  valve,  shewn  in  dotted  line  to  indicate  its  posterior  position. 


47 


48  CARDIAC  OUTLINES. 

(C)  THE  PULMONARY  ARTERY  AND  THE  PULMONARY 
SEMILUNAR  VALVE. 

The  Pulmonary  Artery  is  vertical  in  its  first  portion. 

Its  orifice  and  its  valve  are  therefore  horizontal  ;  and  their  level  is  above 
the  main  level  of  the  aortic  valve.  The  latter,  however,  at  its  left 
extremity,  just  rises  to  the  level  of  the  pulmonary  valve.  In  the 
diagram  are  depicted  at  AP  the  right  and  the  left  anterior  pul- 
monary valve  flaps. 


FIRST    METHOD    OF    TRACING    THE    LATERAL 
LINES    OF    THE    CARDIAC    DIAGRAM. 

(i)  Both  left  lateral  lines,  Ar  and  M'Sc,  have  already  been  described. 

(2)  The  right  lateral  lines  are  also  two  : 

(a)  The  parasternal  line,  in  its  lower  third  ;  and 

(b)  The  vertical  line  C,  which  may  be  termed  the  line  of  the  Vena 

Cava  ;  this  line  is  parallel  and  internal,  by  about  \  inch,  to 
the  parasternal  line. 

(3)  The  line  AOSC  is  drawn  parallel  to  HL,  and  passes  through  the  left 

sterno-clavicular  joint ;  it  roughly  defines  the  upper  limit  reached 
by  the  ascending  Aorta. 

(4)  Lastly,  the  line  Au  Au',  also  parallel  to  HL  and  distant  from  it  only 

one  inch,   is  the  least  essential  of  all  ;    it  gives  the  right  upper 
boundary  of  the  right  auricle,  and  of  the  heart. 

The  slight  difference  observed  between  the  shape  of  the  heart  in  this 
Outline  and  the  most  of  the  others  is  due  to  the  difference  in  the  shape  of 
the  thorax,  which  in  them  has  purposely  been  made  very  broad,  and  also 
to  the  somewhat  low  position  given  to  the  nipples  in  Outline  XVIII.  The 
correctness  of  the  directions  is  not  affected  by  the  imperfections  of  the 
drawing. 


FIG.  XVIII. 


Ao— Outline  of  the  arch  of  the  aorta.  AoSC— Right  upper  boundary 
of  the  arch.  AuAu' — Right  upper  boundary  of  the  heart.  C — Line  of  the 
vena  cava,  external  to  which  is  the  right  lateral  boundary  of  the  heart,  nearly 
coinciding  with  the  parasternal  line,  and  the  dotted  outline  of  the  right 
auricle,  49 


50  CARDIAC  OUTLINES, 


SECOND    METHOD    OF    TRACING    THE    LATERAL 
LINES  OF  THE  CARDIAC  DIAGRAM. 

The  lateral  lines  are  in  this  case  determined  with  the  help  of  skeletal 
landmarks. 

(i)  A  vertical  line  drawn  through  the  5th  chondrocostal  junction  is 
identical  with  the  line  described  as  the  vertical  inner  areolar  line  ; 
and 

(2)  A  line  drawn  through  the  right  sterno-clavicular  joint,  and  through 

the  left  4th  chondrocostal  junction,  is  the  same  as  the  oblique  line 
obtained  vi'ith  the  areola  as  a  landmark. 

(3)  The  parasternal  line  (dotted)  needs  no  comment. 

(4)  The  line  of  the  Vena  Cava  may  be  drawn  from  the  middle  of  the 

right  2d  cartilage,  downwards  ;  or  else,  upwards,  from  the  junc- 
tion of  the  hepatic  line  with  the  upper  border  of  the  6th  cartilage, 
or  more  simply  according  to  the  rule  given  under  Outline  XVIII. 

(5)  The  upper  line  is  obtained  by  joining  the  right    3d    chondrocostal 

junction  with  the  left  sternoclavicular  joint. 


FIG.  XIX. 


The  same  meaning  attaches  to  the  letters  and  numerals  as  in  Fig,  XV. 
IIISC — Right  upper  boundary  of  the  aortic  arch.  IV'SC — Left  oblique 
line.  VI — Line  of  vena  cava.  PS — Parasternal  line,  nearly  coinciding  with 
the  right  lateral  cardiac  boundary. 

51 


52  CARDIAC  OUTLINES. 


THE  HEART'S  OUTLINE  COMPLETED  ACCORDING 
TO  THE  FIRST  METHOD. 

(i)  The  right  lateral  boundary,  belonging  exclusively  to  the  right  auricle,  is 
continued  downwards  from  the  upper  part  of  the  right  auricular  appendix 
in  a  broad  curve  which  touches  the  line  Au  and  the  parasternal  line. 

(2)  Line  C  gives  the  outer  outline  of  the  Inferior  Vena  Cava  ;  and  the 
auricular  orifice  of  the  vein  is  indicated  by  the  6th  cartilage. 

(3)  The  left  lateral  cardiac  outline  forms  a  yet  broader  curv^e  than  the 
right.  This  curve  extends  a  little  beyond  the  oblique  line,  but  barely 
touches  the  vertical  inner  areolar  line. 

(4)  The  Aortic  Arch  rises  into  contact  with  the  line  AOSC  described  in 
Outline  XVI 11. 

(5)  Under  the  Arch  passes,  with  almost  horizontal  direction,  the  right 
branch  of  the  pulmonary  artery,  the  left  division  of  which,  at  first  almost 
vertical,  ultimately  bends  over  the  left  bronchus  and  under  the  Arch. 

(6)  The  right  auriculo-ventricular  boundary  passes  obliquely  downwards 
from  the  middle  point  of  the  sternum  to  its  outer  edge  close  to  the  xiphoid. 

(7)  The  interventricular  line  extends  downwards  with  gentle  curve 
from  the  left  auricular  appendix  to  the  cardiac  apex. 


FIG.  XX. 


J 


,^' 


The  letters  have  the  same  meaning  as  in  previous  Outlines. 
Outlines  XIV.,  XVI.,  XVII.,  and  XVIII. 

53 


Compare 


54  CARDIAC  OUTLINES. 


THE  HEART'S  OUTLINE  COMPLETED  ACCORDING 
TO  THE  SECOND  METHOD. 

The  slight  difference  in  shape  noticeable  between  this  cardiac  Outline  and 
the  preceding  one,  Fig.  XX. ,  mainly  arises  from  the  differences  which  may  be 
traced  between  the  relative  length  and  width  of  the  two  thoracic  diagrams, 
and  between  the  relative  aperture  of  the  infrasternal  angles.  In  reality  the 
shape  of  the  heart  does  not  vary  much  ;  but  its  position  and  that  of  the 
great  vessels,  apd  the  shape  of  the  "presenting"  cardiac  surface,  are  sub- 
ject to  variations  to  suit  thoracic  space.  A  comparison  of  the  two  Outlines 
will  remind  the  student  of  the  importance  which  attaches  (from  the  point 
of  view  of  cardiac  study)  to  a  careful  observation  of  the  individual  peculiari- 
ties in  the  build  of  the  thorax. 


FIG.  XXL 


The  letters  have  the  same  meaning  as  in  previous  Outlines.      Compare 
Outlines  XV.  and  XIX. 


55 


PART  III. 

THE    PRACTICAL   METHODS   OF    INSPECTION 
AND    PALPATION. 

This  is  a  short  account  of  the  subject,  intended  for  tlie  beginner.      It  is 
not  ilUistrated  with  any  diagrams  or  outlines. 

I.  INSPECTION    OF    THE   ANTERIOR    SURFACE    OF    THE 
THORAX  AND  OF  THE  PR.ECORDIUM. 

Observe  any  peculiarity  of  the  anterior  thoracic  surface  : 

(i)  Afiy  ii-regulariiy  in  otitline 

(a)  of  the  clavicles, 

(b)  of  the  sternum, 

(c)  of  the  costal  arch  and  infrasternal  angle, 

(d)  of  the  xiphoid  appendix  ; 

(2)  Any  hjilguig  of  the prcecordhtni  ; 

(3)  Any  a  symmetry  of  the  nipples — 

(a)  in  the  vertical  direction, 

(b)  in  the  horizontal  direction. 

One  or  the  other  form  of  asymmetry  of  the  nipples  is  often  as- 
sociated with  uneven  bulging  of  the  proecordium. 

(4)  Notice  carefully  and  mark  on  the  chest  the  sites  of  any  visible  pulsa- 

tion that  may  be  present  in  the  episternal,  in  the  infrasternal,  or 
in  the  intercostal  spaces  ;  and  especially  the  site  of  the  apex  beat. 

56 


CARDIAC  OUTLINES,  57 

IT.    PALPATION  OF  THE  ANTERIOR  SURFACE  OF  THE 
THORAX  AND  OF  THE  PR/ECORDIUM. 

THE  COSTAL  CARTILAGES  AND  INTERSPACES. 

Our  first  object  in  feeling  the  chest  is  to  ascertain  the  position  of  the 
several  ribs  and  interspaces.  The  experienced  clinical  worker  can  place 
his  finger  at  once  upon  any  rib  or  interspace  he  may  be  desired  to  find. 
The  beginner  has  to  search  for  them.  With  the  help  of  the  following 
methods  this  can  be  done  successfully  and  quickly. 

Counting  the  Costal  Cartilages. — 

(i)  Count  from  above  downwards,  and  in  the  vertical  nipple  line. 

(2)  For  safety  sink  the  edge  of  the  thumb  into  the  interspace  below  the 

cartilage,  whilst  the  index  finger  is  still  on  the  latter,  so  as  to 
always  keep  touch  with  a  cartilage  and  with  an  interspace. 

(3)  Whilst  the  thumb  passes  from  the  interspace  to  the  next   cartilage 

below,  let  the  index  take  its  place  in  the  interspace. 

(4)  Alternate,  after  this  fashion,  the  position  of  the  index  and  of  the 

thumb  until  the  costal  arch  is  reached. 

(5)  The  accuracy  of  the  count  is  confirmed  when  the  last  costal  cartilage, 

ending   in    contact   with    the    xiphoid    cartilage,   is    found    to    be 
the  7th. 

How  to  find  the  First  Costal  Cartilage  and  Interspace. — 

(i)  Feel  with  the  fingers  for  the  sternal  end  of  the  clavicle,  which  it  is 
impossible  to  mistake. 

(2)  Pointing  the  index,  endeavour  to  push  it  upwards  beneath  the  head  of 
the  clavicle  ;  it  will  hitch  against  the  ist  costal  cartilage,  which  may  then 
be  followed  for  some  distance  outwards  until  it  recedes  beneath  and  behind 
the  middle  third  of  the  clavicle. 

(3)  Meanwhile  the  pulp  of  the  finger  will  recognise,  beneath  the  carti- 
lage, the  soft  resistance  of  the  1st  interspace. 

(4)  It  is  a  distinctive  feature  of  the  1st  costal  cartilage  that  the  finger 
cannot  reach  its  upper  border. 

How  to  find  the  Second  Cartilage. — By  some  the  following  method 
is  adopted  in  preference  to  the  preceding  one  : 


58  CARDIAC  OUTLINES. 

(i)  Draw  the  flat  of  the  finger  vertically  along  the  manubrium,  in  the 
middle  line,  till  it  encounters  the  transverse  ridge  formed  by  the  cartilagi- 
nous union  of  that  bone  with  the  gladiolus.  The  2d  cartilage  is  situ- 
ated in  a  line  with  the  ridge,  articulating  with  both  bones. 

In  thin  subjects  the  sternal  end  of  the  second  cartilage  is  generally 
prominent  and  conspicuous  ;  and  the  transverse  ridge  mentioned  above  may 
often  be  seen  independently  of  palpation. 

In  order  to  make  quite  sure  of  the  2d  cartilage  it  is  well  to  press  the 
finger  into  the  interspace  above  it,  and  to  feel  the  ist  cartilage  in  close 
relation  with  the  clavicle. 

Another  simple  method,  applicable  to  thin  subjects,  is  to  run  the  flat  of 
the  index  finger  down  the  chest  in  the  nipple  line,  so  as  to  distinctly  feel 
the  cartilages.  The  highest  cartilage  of  which  the  upper  border  is  thus  felt, 
is  the  2d.  The  ist  cartilage,  as  previously  stated,  only  admits  of  its  lower 
border  being  felt.  ( 

The  Seventh  Cartilage  and  the  Costal  Arch. — The  remaining  carti- 
lages present  no  difficulty  until  the  6th  is  reached.  This  cartilage  and  the 
7th  are  a  little  difficult  to  distinguish  from  each  other  in  the  neighbourhood 
of  the  sternum.  The  7th  may,  however,  be  easily  identified  from  below, 
inasmuch  as  it  is 

(i)  the  last  cartilage  that  can  be  felt  by  the  finger  at  the  lower  part  of 
the  sternum  and 

(2)  the  cartilage  which  forms,  with  the  xiphoid,  the  infrasternal  angle. 

(3)  If,  therefore,  the  finger  be  placed  on  the  xiphoid,  the  cartilage  felt 

on  either  side  of  it  is  the  7th. 

Explore  the  infrasternal  angle  and  the  sides  of  the  costal  arch,  noticing 
the  8th,  9th,  and  lOth  junctions,  and  below  them  the  tip  of  the  nth  rib. 

Observe  the  height  and  the  width  (or  aperture)  of  the  arch  ;  whether  or 
not  symmetrical,  etc.  Ascertain  the  shape  and  the  size  of  the  xiphoid 
appendix,  and  any  deformity  or  malposition  it  may  present. 

THE   NIPPLE. 

Lastly,  find  the  thoracic  site  of  the  nipple.  This  will.be  i:i  front  of,  or 
immediately  below,  the  4th  rib,  about  an  inch  external  to  its  junction  with 
the  cartilage.  Notice  whether  or  not  the  mid-clavicular  line  passes  through 
the  nipple. 


CARDTAC  OUTLINES.  59 

III.    PALPATION  OF  THE  PR^CORDIUM  FOR  CARDIAC 

IMPULSES. 

The  prsecordium  should  once  more  be  explored  by  palpation  as  to  the 
existence  of  any  bulging  (frequently  associated  with  asymmetry  of  the 
nipple)  and  of  any  pulsation  or  thrill. 

Pulsation  should  be  felt  for 

(a)  at  the  apex, 

(b)  at  the  infrasternal  angle, 

(c)  at  the   episternal  notch,   by  hooking  the  index   and  median 

fingers  gently  into  it ;  and 

(d)  over  the  prsecordium  in  general,  by  laying  the  flat  of  the  hand 

over  the  front  of  the  chest. 

THE  APEX-BEAT. 

This  may  be  quite  palpable,  or  may  convey  to  the  finger  only  a  distant 
pulsation.  The  beat  may  happen  to  be  situated  behind  the  rib.  In 
describing  it  notice  should  be  taken  of 

(i)  its  exact  position, 

(2)  whether  it  be  strong  or  weak, 

(3)  small  or  extensive, 

(4)  prominent  or  retractile. 

PULSATIONS    OTHER   THAN    THE   APEX-BEAT. 

Pulsation  at  the  epigastrium  is  common.  It  is  frequently  transmitted  ; 
sometimes  it  is  direct. 

Pulsation  is  often  observed  in  the  left  4th  interspace.  "  In  this  and  in  the 
following  situation  it  is  generally  spoken  of  as  diffused  by  contrast  with  the 
more  circumscribed  beat  at  the  apex. 

Pulsation  in  the  3d  left  interspace  often  accompanies  that  in  the  4th. 

Pulsation  may  also  occur  in  the  2d  left  interspace.  It  may  be  systolic 
in  time. 

There  is  however  another  form  of  pulsation,  sometimes  seen  at  the  left 
2d  interspace,  namely,  a  li?nited  and  diastolic  impulse.  This  is  due  to  the 
diastolic  tension  of  the  sinuses  of  Valsalva  of  the  pulmonary  artery. 


6o  CARDIAC  OUTLINES, 

Pulsation  does  not  occur  on  the  right  side  of  the  chest,  except  when  the 
heart  is  displaced  or  transposed,  and  in  cases  of  aneurysm. 

Pulsation  in  the  episternal  notch  may  be  felt  at  varying  depths  ;  some- 
times it  may  be  felt  or  even  seen  at  the  upper  level  of  the  manubrium. 

IV.     PALPATION  IN  PATHOLOGICAL   CONDITIONS. 

ABNORMAL    IMPULSES    AND    THRILLS. 

In  abnormal  subjects  other  impulses  may  be  felt  besides  that  of  the 
cardiac  apex  ;  and  the  latter  may  itself  be  abnormal. 

ABNORMAL    APEX-BEAT. 

The  chief  abnormalities  of  the  apex-beat  relate  to  its   position,  to  its 
strength,  and  to  its  extent.     Thus  the  apex-beat  may  be 
Displaced,  or 
Too  strong,  or 

Too  widely  felt  (extensive  apex-beat). 
The  heart's  apex  is  so  frequently  hidden  behijid  the  jlh  or  the  6th  rib 
that  the  mere  fact  that  it  cannot  be  felt  beating  does  not  warrant  a  conclu- 
sion that  any  abnormality  exists. 

ABNORMAL   CARDIAC    IMPULSES. 

Cardiac  impulses  may  be  : 
(i)  Direct ; 
(2)  Indirect  or  transmitted. 

One  form  of  trans7nitled  impulse  is  of  frequent  occurrence,  viz.,  the 
indirect  epigastric  pulsation  conveyed  by  the  liver. 

Most  precordial  impulses  are  direct.  Moreover,  there  frequently  occurs 
a  direct  epigasti'ic  cardiac  impulse  which  it  is  important  not  to  overlook. 

The  prcecordial  impulses  are  systolic  or  diastolic  in  time,  and  auricular, 
ventricular,  or  vascular  in  their  origin. 

The  following  table  gives  a  useful  synopsis  of  the  impulses  which  may  be 
felt  over  the  heart  or  in  its  vicinity  : 


CARDIAC  OUTLINES. 


6l 


Palpable 

or 

Tactile 

Impulses. 


Indirect      T  Transmitted  epigastric  pulsation  ; 

^^.       ,   1  Pulsations  conveyed  by  tumours  or  fluid  effusions  ; 
transmitted,  t^ 

Apex-beat  (prominent  or  retractile)  ; 
Left  Ventricular  impulse  ; 
Right  Ventricular  impulse  ; 
Right  Auricular  impulse  ; 
Direct       -|  Epigastric  (infrastcrnal)  impulse  ; 
Pulmonary  systolic  impulse  ; 
Pulmonary  diastolic  impulse  ; 
Aortic  systolic  impulse  ; 
Aortic  diastolic  impulse. 


A  discussion  of  the  mode  of  production  and  of  the  diagnostic  value  of  the 
various  cardiac  impulses  cannot  be  attempted  in  these  pages.  The  same 
remark  applies  to  the  thrills,  which  may  be  classified  as  follows  : 


ABNORMAL   PRECORDIAL   THRILLS. 


Thrills  may  be  produced  within  the  heart  or  outside  it ;  in  other  words, 
they  may  be  endocardial  or  exocardial. 

Endocardial  Thrills  may  be  localised  \.o  one  part,  ox  general — that  is, 
felt  over  the  whole  praecordium. 

No7i-localised  or  general  endocardial  thrills  are  usually  either  congenital, 
or  due  to  aortic  valvular  stenosis,  or  to  aortic  aneurysm  ;  and  in  all  these 
cases  they  are  usually  systolic. 

Localised  endocardial  thrills  may  be  due  to  defect  of  any  of  the  heart 
valves,  although  uncommon  in  connection  with  the  right  heart.  A  thrill 
may  occur  also  when  the  valves  are  normal,  as,  for  instance,  in  anaemia  or 
as  a  result  of  pressure. 

A  /^ezVra/ valvular  thrill  is  usually  diastolic  or  praesystolic  ;  an  <zcr/eV  valvu- 
lar thrill  more  commonly  systolic. 

Exocardial  Thrill  is  usually  the  result  oi pericardial  friction.  It  may 
occasionally  be  produced  by  friction  within  the  praecordial  portion  of  the 
pleural  sac  (pleuro-pericardial  friction). 


62  CARDIAC  OUTLINES. 

PALPATION    FOR    IMPULSES    AND    THRILLS    IN    PERICAR- 
DITIS. 

In  view  of  its  importance  this  subject  claims  to  be  separately  considered  : 

In  Fibrinous  Pericarditis  a /riV/'zi7«-///r/// is  usually  perceptible,  and 
is  often  very  marked.  It  may  be  general,  or  limited  to  a  portion  of  the  prae- 
cordium.  When  of  limited  extent,  it  is  more  commonly  felt  over  the  middle 
than  over  the  lower  third  of  the  sternum.  When  faint,  it  may  be  intensified 
by  pressure.  Pericardial  friction-thrill  is  not  conducted  beyond  the  seat  of 
its  production.  This  is  a  useful  point  of  distinction  between  it  and  some  of 
the  vascular  thrills. 

In  Adhesive  Pericarditis  palpation  does  not  afford  us  much  assistance. 
Systolic  retraction  of  the  region  of  the  apex  is  not,  in  itself,  a  reliable  sign. 
When  associated  with  diastolic  impulse  it  acquires  greater  diagnostic  value. 
The  late  secondary  changes  undergone  by  the  heart  are  to  a  certain  extent 
perceptible  by  palpation,   but  they  are  not    distinctive  of  the   condition. 

In  Pericarditis  with  Effusion  there  may  be  noticed  on  palpation,  if 
the  collection  of  fluid  be  a  large  one,  some  bulging  of  the  whole  dull  area 
and  of  the  intercostal  spaces  within  it.  The  cardiac  impulse  may  be  totally 
absent,  or  perceptible  only  when  the  patient  lies  down  ;  or  it  may  be  readily 
felt.  A  cardiac  impulse  occurring  above  the  lower  limit  of  the  dull  area  is* 
diagnostic,  especially  if  change  in  position  should  modify  the  shape  of  the 
dull  area  according  to  the  laws  of  gravitation. 


PART  IV. 

,:ardiac  percussion  and  the  "percussion" 

series  of  outlines  (normal  and 

pathological). 

The  importance  and  difficulty  of  this  section  of  cardiac  study  have  necessi- 
tated the  introduction  of  a  set  of  graduated  Outlines,  illustrating  step  by 
step  the  method  to  he  followed,  and  the  results  to  he  obtained. 

GENERAL    REMARKS    ON    CARDIAC    PERCUSSION. 

The  reader  is  supposed  to  be  familiar  with  the  general  principles  and 
methods  of  percussion,  and  these  apply  to  the  physical  examination  of  the 
heart  as  they  do  to  that  of  any  other  organ, 

A  great  deal  can  be  accomplished  by  unaided  finger  percussion  ;  and 
until  this  mode  of  percussion  has  been  mastered,  the  student  should  attempt 
no  other.  For  the  purposes  of  the  more  advanced  clinical  worker  Sansom  s 
pleximeter  possesses  decided  advantages,  which  will  be  explained  presently. 

The  special  need  in  cardiac  percussion  x-^  precision.  We  should  be  able 
to  obtain  an  accurate  idea  of  the  size  of  the  heart,  in  all  its  diameters, 
except  the  antero-posterior  ones.  This  can  be  done,  in  spite  of  the  constant 
alterations  in  size  and  in  shape  which  the  organ  undergoes,  since,  owing  to 
the  short  duration  of  the  systole,  we  are  for  practical  purposes  always  per- 
cussing the  heart  during  its  diastole. 

The  Dermographic  Method. — Correct  demarcation  is  the  highest  aim 
of  percussion  ;  it  is  also  the  quickest  way  to  acquire  precision.  Endeavour, 
therefore,  to  trace  out  the  results  of  percussion  on  every  suitable  occasion. 

N^ver  be  without  a  dermographic  pencil,  and  begin  to  use  it  independently 

63 


64  CARDIAC   OUTLINES, 

at  your  earliest  clinical  opportunity.  Having  made  out  your  own  markings, 
get  one  of  your  seniors  to  verify  them.  Then  go  over  the  work  again,  thei)et- 
ter  to  perceive  your  mistakes  and  their  corrections.  Your  progress  may  be 
rapid  or  it  may  be  slow  ;  if  it  should  be  slow,  so  much  the  greater  was  your 
need  for  practice,  and  so  much  the  greater  will  be  your  ultimate  gain. 

THE  METHOD  OF  PERCUSSING. 

On  the  use  of  the  single  and  of  the  double  Percussion  Stroke. 
— In  percussing  the  cardiac  dulness  in  the  dead  body,  a  single  stroke  is 
enough  to  decide  whether  the  spot  percussed  be  resonant  or  dull.  During 
life  the  movements  of  the  lungs  and  of  the  heart  are  an  excuse  for  repeating 
the  stroke,  since  they  might  possibly  interfere  with  a  correct  estimate  of 
the  amount  of  dulness  or  of  resonance  at  any  given  spot. 

Multiple  percussion,  which  elsewhere  is  not  to  be  recommended,  is  there- 
fore advisable  in  cardiac  percussion.  By  this,  however,  is  not  meant  a  con- 
fusingly rapid  peal  of  taps,  but  two — or  at  most  three — deliberate  strokes, 
with  time  enough  between  them  to  appreciate  the  note  struck  at  each  blow. 

SHORT  RULES  FOR  SAFE  AND  RAPID  PERCUSSION. 

It  is  not  enough  to  know  how  to  map  out  the  heart  correctly  ;  we  must 
learn  to  do  it  quickly,  and  yet  reliably.  The  following  methods  will  save 
time,  and  will  be  found  useful  even  by  advanced  students  ;  whilst  they  are 
invaluable  to  the  beginner  : 

(i)  Before  percussing  the  heart,  a  standard  of  complete  pulmonary  reso- 
nance must  be  sought  at  a  safe  distance  from  the  prcecordium.  be 
it  at  the  upper  pectoral  region,  or  in  the  anterior  axillary  line. 

(2)  A  standard  of  complete  cardiac  dulness  should  next  be  obtained  by 

percussing  the  5th  cartilage  or  interspace  in  the  left  parasternal 
line. 

(3)  For  the  rapid  discovery  of  the  line  which  separates  complete  pulmo- 

nary resonance  from  the  partial  cardiac  dulness  ("  partial  "  owing 
to  the  influence  of  the  thin  covering  of  resonant  lung),  it  is  essential 
to  bear  in  mind  the  shape  of  the  cardiac  outline  which  has  been 
depicted  in  the  preceding  diagrams, 


CARDIAC  OUTLINES.  65 

(4)  The   direction   of  the    finger  or   pleximeter    must  in   every   case  be 

parallel  with  that  of  the  line  for  which  we  are,  at  the  time, 
percussing.     Therein  lies  the  secret  of  accurate  results. 

(5)  Thus,  if  we  should  want  to  define  a  vertical  portion  of  the  cardiac 

outline,  the  finger  or  pleximeter  must  be  applied  to  the  chest 
vertically  ;  if  a  horizontal  portion  of  the  outline  be  wanted,  then 
the  pleximeter  must  be  horizontally  placed.  Let  us  imagine,  for 
example,  a  case  in  which  we  are  quite  ignorant  as  to  the  distribu- 
tion of  the  dulness  and  of  the  resonance,  and  in  which  their 
boundary  is  vertical — the  ease  with  which  this  boundary  will  be 
found  will  vary  with  the  direction  given  to  the  finger  or  pleximeter. 
If  the  flat  of  the  finger  be  placed  horizontally,  any  percussion  of  it 
will  elicit  a  mixed  sound  arising  partly  from  the  resonant  and 
partly  from  the  dull  surface  ;  however  prolonged  our  percussion  in 
this  position,  we  shall  be  none  the  wiser.  Should,  however,  the 
finger  be  applied  vertically,  the  note  obtained  will  then  be  that 
either  of  the  dull  or  of  the  resonant  area.  By  slightly  shifting  the 
finger  (whilst  preserving  its  longitudinal  direction)  we  shall  at  once 
have  an  opportunity  of  appreciating  the  different  notes  special  to 
the  two  surfaces. 

A  like  success  will  attend  our  percussion  of  the  several  boundary 
lines  of  the  heart's  partial  dulness,  if  only  we  are  careful  to  per- 
cuss in  directions  parallel  to  each  of  them. 

(6)  The  two  alternatives  would  be  :  (a)  either  to  percuss  at  each  stroke  a 

very  limited  area,  no  larger  than  the  tip  of  the  finger, — a  time-con- 
suming and  perplexing  task  ;  (b)  or,  if  using  the  length  of  the 
finger,  to  endeavour  by  shifting  its  axis  to  find  the  position  in  which 
percussion  yields  a  definite  line  of  demarcatjpn.  We  are  spared 
all  this  trouble  by  adopting  at  once  positions  parallel  to  the  lines 
of  the  normal  cardiac  outline. 
N.  B.     Cammann's  method  of  auscultatory  percussion  is  not  described 

in  these  pages,  the  ordinary  method  being  simpler,  and  yielding  results 

which  are  entirely  satisfactory. 
5 


66 


CARDIAC   OUTLINES. 


SANSOM'S  PLEXIMETER. 

Most  pleximeters  have  this  in  common,  that  their  chest- piece  is  straight, 
at  least  on  one  side  ;  and  readily  adapted  to  the  direction  of  straight  lines  of 
dulness,  such  as  have  been  described. 

On  the  other  hand,  they  all  modify  the  sounds 
of  percussion  more  than  does  mediate  finger  per- 
cussion.* This  reproach  also  attaches  to  Sansom's 
plexinieter,  although  in  a  less  degree  than  to  any 
with  which  the  author  is  acquainted. 

Through  Dr.  Sansom's  kindness  he  is  able  to 
give  an  illustration'  of  the  pleximeter.  The 
instrument  is  made  of  vulcanite  and  measures 
4  cm.  in  height  ;  its  longer  flange  A  4tv;/.,  its 
smaller     flange    B   2   cm.    only    in    length.       The 


FIG.  XXII. 

sansom's  pleximeter 


width  of  each  flange  is  13  mm. 


WHAT  TO  AVOID  IN  CHOOSING  A  SANSOM'S  PLEXIMETER. 


The  pattern  seen  in  Fig.  XXII  is  obsolete  and  should  be  avoided  in 
making  a  selection.  Its  fault  lies  in  the  sharpness  of  the  angles,  which 
occasions  pain  to  the  patient. 

The  second  illustration,  Fig.  XXIII,  shews  the  corners  rounded  off.  It 
also  shews  rather  more  substantial  flanges  than  those  seen  in  the  original 
pattern.  The  purchaser  should  select  flanges  of  medium  thickness,  just 
thick  enough  to  resist  the  attempt  to  bend  them.  The  very  thin  flanges 
bend  readily,  and  are  brittle  ;  neither  are  they  so  well  adapted  for  their 
special  purpose  as  rather  thicker  ones. 

*  For  further  remarks  on  this  subject  see  the  author's  clinical  lecture  "  On  the  value  of 
accuracy  in  cardiac  percussion,"  Lancet^  August  29,  1891. 


CARDIAC  OUTLINES. 
HOW    TO    USE   A    SANSOM'S    PLEXIMETER. 


67 


FIG.  XXIII. 

THE   PLEXIMETER    IN    USE. 


Little  explanation  is  needed  for 
Fig.  XXIII.,  which  shews  the  usual 
arrangement,  viz.,  the  long  flange 
used  as  the  chest-piece,  the  small 
flange  as  the  anvil,  and  the  finger- 
tip as  the  hammer. 

The  position  can  be  reversed 
whenever  a  very  small  chest-piece 
is  desirable.  This  facility  is  often 
a  valuable  help. 

The  figure  represents  the  method 
(recommended  by  Dr.  Sansom)  of 
holding  the  instrument  by  the 
lateral  pressure  of  the  2d  and  3d 
fingers,  their  pulp  resting  on  the 
flange,  and  being  accessible  through 
it  to  almost  all  the  chest  vibrations 
elicited  by  percussion. 


ENUMERATION    OF    SOME   OF    THE  ADVANTAGES  OF   THE 

PLEXIMETER. 


Among  the  advantages   special   to    Sansom's   pleximeter  may  be   men- 
tioned : 

(i)  Its  lightness, 

(2)  Its  small  size  and  portability, 

(3)  Its  ability  to  fit  in  awkward  hollows  which  some  fingers  can  hardly 

reach, 

(4)  Its  reversibility, 

(5)  The  ease  with  which  its  pressure  may  be  regulated  by  the  finger, 

(6)  The  straightness  of  its  edges,  which  favours  rapidity  quite  as  much  as 

might  the  same  length  of  the  flat  of  the  finger,  whilst  affording 
superior  sharpness  in  the  results, 


68  CARDIAC   OUTLINES, 

(7)  The  facility  given  for  measurements,  since  millimetres  or  lines  might 

be  marked  on  the  upper-face  of  the  flange, 

(8)  The  inherent  fault  previously  mentioned  is — for  cardiac  percussion— 

also  to  be  reckoned  among  the  special  advantages.     This  pleximeter 

intensifies  dulness,  at  the  same  time  that  it  defines  more  sharply 

the  dull  border. 

Therefore,  if  doubt  should  occur  as  to  the  value  of  any  sounds  obtained 

by  immediate  finger    percussion,  the   pleximeter  would   probably   decide. 

In  this  power  for  discrimination  lies  a  yet  stronger  recommendation  than 

in  the  practical  advantages  which  have  been  enumerated. 


CARDIAC  OUTLINES.  69 

"PERCUSSION"    SERIES    OF    OUTLINES. 

THE    CARDIAC    SURFACE    LEFT    UNCOVERED    BY 

THE  LUNGS. 


covering 
parts  : 


The  accompanying  illustration 

will  remind  the  student  of  the  rela- 

^\^     I  /Ny^         ">s>^     tion  existing  between  the  anterior 

-OM^  V— — -^ — ^^  pulmonary  borders  and  the  heart, 

which  is  not  depicted  here,  but 
which  occupies  the  interval  be- 
tween them.  The  right  and  the 
left  upper  lobe  come  into  close 
relation  with  each  other  behind 
the  sternum  on  a  level  with  the 
2d  and  3d  cartilages.  Below  the 
latter  they  diverge.  The  fringe 
of  the  left  upper  lobe  receding 
much  farther  and  much  more 
abruptly  than  that  of  the  right, 
gives  rise  to  the  gap  known  as  the 
cardiac  incisure. 

The  portion  of  the  prsecordium 
devoid  of  any  anterior  pulmonary 
will  be  seen  in  Outline  XXVIII.  to  correspond  to  the  following 


FIG.   XXIV. 


The  lower  third  of  the  sternum, 

Part  of  the  left  5th  cartilage, 

Part  of  the  left  6th  cartilage, 

A  small  portion  of  the  4th  interspace. 

The  greater  part  of  the  5  th  interspace. 

Over  this  extent  of  surface  nothing  but  pericardium  and  areolar  tissue 
intervenes  between  the  heart  and  the  anterior  thoracic  wall. 


JO  CARDIAC  OUTLINES, 

THE    AREA    OF    ABSOLUTE     CARDIAC     DULNESS. 

The  heart,  when  isolated,  being  absolutely  dull  on  percussion,  absence 
of  any  pulmonary  tissue  over  the  space  described  in  the  previous  diagram, 
would  entail  absence  of  resonance.  It  is  found,  however,  on  percussing  the 
chest,  that  absolute  dulness  does  not  extend  over  the  whole  area  unoccupied 
by  lung.  This  is  due  to  the  facility  with  which  the  sternum  conducts 
sound.  In  its  upper  part  this  bone  receives  sonorous  vibrations  from  the 
underlying  lung  tissue,  and  these  are  transmitted,  almost  unaltered,  as  far 
as  its  lower  extremity.  Consequently  the  dulness  obtained  when  the  lower 
sternum  is  percussed  is  not,  as  it  otherwise  would  be,  absolute  in  degree. 
Absolute  cardiac  dulness  begins  only  at  the  left  border  of  the  sternum  ; 
this  is  its  limit  towards  the  right.  Its  remaining  boundaries  are  identical 
with  those  of  the  cardiac  incisure  of  the  left  upper  lobe. 

ITS    SHAPE   AND    SIZE. 

These  are  apt  to  vary  not  only  in  disease,  which  we  exclude  from  our 
present  consideration,  but  also  in  the  healthy  chest,  because  the  shape  and 
size  of  the  cardiac  incisure  are  slightly  variable.  On  this  point  published 
descriptions  do  not  all  agree,  some  giving  a  circular,  others  a  triangular 
shape  as  that  of  the  normal  area  of  absolute  dulness.  This  need  not 
puzzle  the  student.  The  question  is  one  of  anatomy,  which  he  can  settle 
for  himself  at  any  autopsy.  The  shape  of  the  cardiac  incisure  of  the  left 
lung  is  also  the  shape  of  the  absolute  dulness  of  the  heart  ;  and  in  size  they 
are  also  identical,  with  the  exception  mentioned  above,  that  absolute  dul- 
ness does  not  extend  behind  the  sternum,  although  space  is  there  occupied 
by  the  heart.  The  boundaries  of  the  area  of  absolute  dulness  are,  there- 
fore, in  a  majority  of  subjects  : 

laterally  :  (i)  The  left  sternal  border,  and  (2)  A  vertical  line  a  little 

internal  to  the  lower  part  of  the  left  inner  areolar  line  ; 
above  :   (3)  A  line  passing  obliquely  from  the  left  4th  sternal  junction 
to  the  lower  border  of  the  5th  cartilage,  where  the  latter  is  crossed 
by  the  lateral  boundary, 
below  :  (4)  The  hepatic  line. 
The  shape  is  seen  to  be  a  trapezoid  or  a  truncated  triangle.     For  practi- 
cal purposes  the  area  of  absolute  dulness  may  be  regarded  as  triangular. 


FIG.    XXV. 


This  Outline  should  be  compared  with  Outline  XXVI.,  and  with  Out- 
lines showing  the  heart  in  situ.  The  left  vertical  boundary  of  dulness  will 
be  noticed  to  be  slightly  internal  to  the  apex-beat  X. 


71 


^2  CARDIAC  OUTLINES, 

FIRST    STEP   IN   THE    EXAMINATION   OF   THE 
HEART  BY  PERCUSSION  : 

HOW  TO  DETERMINE  THE  ABSOLUTE  HEPATIC  DULNESS. 

A  preliminary  percussion  of  the  liver  is  the  safest  and,  to  the  experienced 
clinical  observer,  also  the  shortest  way  of  determining  the  area  of  cardiac 
dulness  ;  it  has  for  its  special  object  to  find  the  line  HX — the  "hepatic 
line" — which  corresponds  to  the  level  of  the  floor  of  the  pericardium. 

METHOD    OF    PERCUSSING. 

(1)  If  possible,  find  the  apex-beat,  X,  and  mark  the  spot  on  the  chest. 

(2)  Place  the  finger  horizontally  in  the  4th   right  interspace,   one  inch 

internal  to  the  right  nipple  line.      This,  on  being  percussed,  will 
yield  a  fully  resonant  note. 

(3)  Transfer  the  finger  to  the  6th  interspace,   or  7th   cartilage,    in   the 

same  vertical  line,  still  keeping  it  horizontal,  and  percuss  again. 
This  will  give  an  absolute  dull  note,  that  of  the  liver. 

(4)  Percuss  next  in   the   5th  space,   just  below  the   5th  cartilage.       The 

note  will  no  longer  be  absolutely  resonant  ;  but 

(5)  If  the  6lh  cartilage,  just  internal  to   H,  be  now  percussed,  a  much 

duller  sound  will  result. 

(6)  To  make  out  with  precision  the  line  HX  is  now  merely  a  c[uestion  of 

attentive  percussion. 

(7)  Taking  the  highest  point  in  the  line   HX,  join   it  to  a  spot  imme- 

diately beneath  the  apex-l^eat,  X. 

(8)  By  a  similar  process  the  line  IH  will  be  found, 

(9)  Any  part  of  the  outline  included  between  these  two  lines,  as  far  as 

the  left  border  of  the  xiphoid  cartilage,  will  yield  an  absolutely 
dull  sound  ;  but 

(10)  Beyond  the  xiphoid  the  hepatic  dulness  unll  cease  to  he  absolute  ;  and 

the  degree  of  the  change  will  vary  according  as  the  stomach,  G, 
is  inflated,  full,  or  empty. 

(11)  The  change  is  always  from  greater  to  less  resonance  as  we  pass  from 

the  right  to  the  left  portion  of  the  liver. 


FIG.  XXVI. 


This  Outline  should  be  compared  with  the  following  Outlines  belong- 
ing to  the  same  series.  HX — The  upper  limit  of  absolute  dulness  of  the 
liver.      Ill — The  inferior  hepatic  border. 


73 


74  CARDIAC  OUTLINES. 

SECOND  STEP  IN  CARDIAC  PERCUSSION  : 

HOW  TO  DETERMINE  THE  ABSOLUTE  CARDIAC  DULNESS. 

(i)   The  lower  boundary  we  have  already  secured,  since  it  forms  part  of 
the  hepatic  line  HX. 

(2)  In  order  to  find  the  right  boundary,  place  the  finger  to  be  percussed 

vertically  in  the  5th  interspace,  one  and  a  half  inch  to  the  left  of 
the  sternum  :  the  note  struck  here  will  be  absolutely  dull  ; 

(3)  Now  percuss  over  the  middle  of  the  sternum.     This  will  be  much  less 

dull,  perhaps  even  resonant  ;  and  a  boundary  will  be  readily  traced 
between  the  dull  and  the  resonant  parts,  coinciding  with  the  left 
sternal  1j  order. 

(4)  This  line  of  dulness  will  be  found  to  extend  along  the  left  edge  of  the 

sternum,  from  the  lower  border  of  the  4th  cartilage  to  the  hepatic 
line. 

(5)  In  seeking  to  determine   the  left  boundary,  we  should  compare  the 

percussion  note  of  the  dull  area,  as  far  as  made  out  hitherto,  with 

the  full  resonance  of  the  left  3d  and  4th  interspaces,  outside  the 

nipple  line, — neglecting  for  the  present  the  partial  dulness  which 

may  be  detected  in  the  left    outer  and   upper  part  of  the  proe- 

cordium.      The  observer  will  easily  work  out  the  oblique  boundary 

line  depicted  in  the  diagram  by  alternately  percussing  the  dull  and 

the  resonant  surfaces. 

The  present   Outline,  shewing   the  combined   areas  of  absolute  dulness, 

cardiac  and  hepatic,  illustrates  the  results  arrived  at  so  far.     The  dull  area 

of  the  heart  and  that  of  the  liver  have  a  boundary  in  common,  viz. :  the 

hepatic  line.      We  have  assumed  that  this  line  followed  a  straight  course, 

but  of  this  we  have  not  supplied  evidence.      In  other  words,  that  portion  of 

the  hepatic  line  which  extends  between  the  infrasternal  notch  and  the  cardiac 

apex  has  not  been   determined  by  percussion,  but  in  an  indirect  way.      This 

is  a  weak  point  which  will  presently  claim  further  attention. 


FIG.  XXVII. 


Compare  Outlines  XXV.  and  XXVI.  The  dulness  of  the  two  areas  is 
continuous  in  the  left  chest,  although  not  of  identical  qtiality.  The  left 
portion  of  the  hepatic  line  is  almost  occluded. 

75 


76  CARDIAC   OUTLINES. 

THE  RESPIRATORY  VARIATIONS  OF  THE  LEFT  OR  UPPER 
BOUNDARY  OF  ABSOLUTE  CARDIAC  DULNESS. 

We  have  hitherto  spoken  of  the  boundaries  of  the  absolutely  dull  area  as 
though  they  were  constant,  at  least  in  the  same  individual.  This  is  not 
the  case.  They  all  vary  with  respiration,  but  the  variation  is  noticeable 
only  in  the  left  upper  boundary,  and  in  the  hepatic  line. 

I.  So  long  as  no  pleural  or  pericardial  adhesions  exist,  the  effect  of  a 
deep  inspiration  is  to  cause  the  left  upper  lobe  of  the  lung  to  expand  down 
to  a  lower  limit  than  previously.  Its  inferior  border  will  cover  from  above 
more  of  the  cardiac  surface  ;  and  the  absolute  dulness  will  be  reduced  by  so 
much.  Conversely,  the  next  expiration  will  correct  this  encroachment. 
Therefore,  held,  forcible  expirations  may  lead  to  a  more  than  average  size 
of  the  dull  area.  These  changes  will  not  result  if  either  the  upper  lobe  of 
the  left  lung,  or  the  anterior  surface  of  the  heart  l^e  closely  united  by 
adhesions  to  the  anterior  chest-walls. 

II.  Meanwhile,  unless  the  heart  be  closely  adherent  to  the  pericardium 
and  to  the  chest-wall,  a  forcible  inspiration  will  depress  the  central  portion 
of  the  diaphragm  by  an  appreciable  amount.  The  dull  area,  encroached 
upon  from  above,  will  thus  tend  to  be  increased  downwards.  During 
forcible  expiration  the  converse  change  will  take  place.  But  the  range  of 
movement  of  the  central  tendon  of  the  diaphragm  is  much  more  restricted 
than  that  of  the  pulmonary  fringe  ;  and  the  variations  in  the  size  of  the  dull 
area  will  be  governed  by  the  movements  of  the  latter. 

From  these  facts  the  following  conclusions  may  be  drawn  : 
(i)  The  size  of  the  area  of  absolute   dulness  is  in  health  not    fixed  but 
variable. 

(2)  It  increases  with  each  expiration,  and  lessens  with  each  inspiration, 

proportionately  to  the  depth  of  the  breathing. 

(3)  The  mobility  of  the  oblique  line  (or  left  boundary')  of  dulness  is,  in 

itself,  evidence  that  close  adhesions  do  not  exist  between  the 
left  upper  lobe  and  the  chest  wall,  nor  between  the  latter  and  the 
front  of  the  heart. 

(4)  A  determination,  in  individual  cases,  of  the  presence  or  absence  of 

the  respiratory  variations  in  question,  is,  therefore,  practically 
useful  for  purposes  of  diagnosis. 


FlC).    XXVIII. 


The  anterior  edges  of  the  lungs  are  shown  in  interrupted  black  line. 
The  lungs  are  supposed  to  be  rather  fully  inflated.  During  forced  expira- 
tion the  oblique  loM'er  border  of  the  left  upper  lobe  would  approach  the  level 
of  the  fourth  cartilage. 

77 


78  CARDIAC   OUTLINES, 

THIRD  STEP  IN  CARDIAC  PERCUSSION  : 

HOW    TO    DETERMINE    THE    PARTIAL    DULNESS    OF    THE 

LIVER. 

The  hepatic  line  HX,  shewn  in  the  Outlines,  does  not  represent  the  high- 
est level  of  the  liver  within  the  thorax,  but  only  that  level  below  which  the 
liver  is,  and  above  which  it  is  not,  in  contact  with  the  anterior  thoracic 
wall.  Our  present  business  is  to  determine  the  upper  hepatic  boundary. 
The  interval  between  the  chest  wall  and  the  receding  hepatic  surface  being 
normally  occupied  by  lung,  we  shall  expect  any  dulness  due  to  the  liver  to 
be  toned  down  by  so  much  pulmonary  resonance.  This  modification  is 
best  described  by  the  term  "  partial  dulness"  (in  preference  to  "  deep  dul- 
ness," which  is  an  ambiguous  expression). 

Percussors  usually  determine  the  upper  hepatic  boundary  in  the  inner 
inframammary  region  ;  and  this  is,  in  every  way,  the  most  favourable  situa- 
tion to  select  for  this  purpose. 

The  boundary  sought  will  be  found  without  difficulty  by  alternately  per- 
cussing the  right  4th  and  5th  interspaces,  between  the  nipple  and  the 
parasternal  lines.  In  the  Outline  it  occupies  the  level  of  the  5th  cartilage  ; 
but  the  student  will  bear  in  mind  that,  as  stated  above,  its  position  is 
a  varying  one.  Each  deep  inspiration  will  cause  a  perceptible  descent  of 
the  liver,  which  will  rise  again  with  expiration. 

For  ordinary  purposes  this  simple  determination  of  level  will  suffice.  The 
student,  however,  should  complete  the  examination  by  percussing  out  the 
boundary  of  partial  dulness  towards  the  right  extremity  of  the  liver,  as 
shewn  in  the  present  Outline,  and  towards  the  left,  as  will  be  described 
further  on.  The  boundaiy  in  question  is  seen  to  have  a  nearly  horizontal 
portion,  that  nearer  the  middle  line  ;  and  a  curved  descending  portion,  that 
extending  towards  the  axillary  line. 

The  horizontal  portion  may  conveniently  be  termed  "the  suprahepatic 
line."  This  name,  which  the  author  has  ventured  to  introduce,  conveys  its 
own  explanation.  Taken  in  conjunction  with  the  equally  clear  expressions, 
" infrahepatic  line,"  or  "lower  hepatic  border, "  it  illustrates  by  contrast 
the  meaning  of  the  term,  "  hepatic  line,"  previously  described. 


FIG.  XXIX. 


HX — The  hepatic  line,  or  upper  boundary  of  absolute  hepatic  dulness. 
SH — The  suprahepatic  line,  or  upper  boundary  of  the  liver,  and  of  the  partial 
hepatic  dulness.     IH — The  infrahepatic  line,  or  lower  border  of  the  liver. 


79 


8o  CARDIAC  OUTLINES. 


FOURTH  STEP  IN  CARDIAC  PERCUSSION. 

HOW  TO  DETERMINE  THE  PARTIAL  CARDIAC  DULNESS  IN 
THE  RIGHT  HALF  OF  THE  CHEST. 

In  this  somewhat  more  difficult  portion  of  the  examination  we  must 
chiefly  rely  upon  the  fairly  sharp  contrast  given  by  the  fully  resonant  lung  in 
the  mammary  region.  We  have  not  in  this  case  any  equivalent  degree  of 
cardiac  dulness  to  compare  with  the  full  pulmonary  resonance.  The  sternal 
portion  of  the  prascordium  is  resonant,  and  the  right  parasternal  portion  is 
hardly  ever  quite  dull.  Nevertheless,  when  percvxssing  from  left  to  right, 
the  trained  percussor  (especially  if  using  the  pleximeter)  will  not  miss  the 
line  at  which  the  partially  resonant  note  suddenly  acquires  unmixed  clear- 
ness as  he  passes  beyond  the  extreme  right  cardiac  boundary. 

In  order  successfully  to  conduct  this  examination  the  finger  to  be  per- 
cussed must  be  moved  from  the  horizontal  into  the  vertical  position  ;  this 
will  facilitate  a  determination  of  the  vertical  line  shewn  in  the  diagram. 


FIG.  XXX. 


HX — The  hepatic  line.  SH — The  suprahepatic  line.  The  shaded 
portion  of  the  sternal  and  right  parasternal  regions  represents  partial  dulness. 
The  space  left  blank  has  not  yet  been  carefully  percussed. 


8i 


82  CARDIAC   OUTLIArES, 


FIFTH   STEP  IN  CARDIAC   PERCUSSION. 

HOW   TO   DETERMINE   THE    PARTIAL    CARDIAC    DULNESS 
IN  THE   LEFT  HALF  OF  THE  CHEST. 

The  left  boundary  of  partial  dulness  is  rather  more  difficult  to  find  than 
the  right.  In  attempting  this  percussion  it  is  therefore  advisable  to  consult 
at  first  the  normal  cardiac  Outline.  Here  again  as  in  the  preceding  stage, 
the  fulness  of  the  pulmonary  resonance  with  which  the  partial  dulness  has  to 
be  compared  renders  the  task  somewhat  easier.  In  the  Outline  the  oblique 
boundary  is  seen  to  follow  the  line  joining  the  3d  left  chondrosternal 
junction  to  the  4th  left  chondrocostal  junction. 

The  shorter  vertical  boundary,  which  extends  from  the  left  nipple  level 
to  the  hepatic  line,  is  often  somewhat »obscured  by  conducted  resonance  due 
to  the  stomach.  This  occurs  almost  invariably  at  the  lower  extremity  of 
the  line  :  and  the  surface  corresponding  to  the  apex-beat  is  found  to  be  rela- 
tively resonant,  instead  of  belonging,  as  it  otherwise  would,  to  the  area  of 
absolute  dulness,  or  ac  least  to  tlie  partly  dull  area. 

In  the  female  a  determination  of  the  left  area  of  partial  dulness  is  diffi- 
cult and  apt  to  be  painful,  and  should  not  be  insisted  on  as  a  matter  of 
routine. 

N.  V>.  Within  the  region  of  partial  dulness  the  student  may  often  observe  more  or  less 
definite  differences  in  the  note  of  percussion.  He  should  not  be  led  away  by  these  less  im- 
portant distinctions  from  the  broad  lines  which  have  been  described.  Mention  may,  how- 
ever, be  made  hereof  tlie  two  accessory  lines  of  incipient  dulness  seen  in  Outline  XXXII., 
one  at  the  right  anterior  thoracic  base,  the  other  at  the  left  upper  thoracic  region.  They 
are  not  practically  of  importance  to  the  beginner. 


FIG.    XXXI. 


HX— The  hepatic  line.  SH— The  suprahepatic  line.  The  shaded 
surface  of  partial  dulness  in  the  left  chest  is  bounded  above  by  an  oblique 
line  and  to  the  left  by  a  vertical  line,  which  are  described  on  the  opposite 
page. 

83 


84  CARDIAC   OUTLINES. 

SIXTH  STEP  IN   CARDIAC  PERCUSSION  : 

HOW    TO  DETERMINE  THE  PR^VASCULAR  DULNESS. 

Careful  percussion  conducted  across  from  the  right  to  the  left  parasternal 
line  will  not  fail  to  detect  variations  in  the  degree  of  resonance.  No  part 
of  this  surface  is  absolutely  dull,  although,  as  a  whole,  it  is  noticeably  less 
resonant  than  the  neighbouring  regions.      This  change  is  due 

(i)  Partly  to  the  increasing  thinness  of  the  pulmonary  fringe, 

(2)  Partly  to  the  density  of  the  mediastinal   contents  (mainly  vessels, 

hence  the  expression  "  prgevascular  dulness  "),  and 

(3)  Partly  also  to  the  Sternum. 

THE    STERNAL    NOTE. 

The  Sternum  has  already  been  described  as  a  conductor  of  the  sonorous 
pulmonary  vibrations.  Equally  well  must  it  conduct  the  less  ample  vibra- 
tions described  as  "high-pitched"  or  "dull,"  which  arise  from  denser 
structures  in  contact  with  it.  From  this  conflict  or  combination  of  vibra- 
tions results  an  "average  sternal  note,"  which  in  the  upper  chest  is  less 
resonant,  in  the  lower  chest  more  resonant,  than  the  note  elicited  on  either 
side  of  the  bone,  and  which  enables  us  to  define  by  percussion  the  shape  of 
the  sternum.  Indeed  we  cannot  avoid  this  determination  ;  it  forms  part 
of  every  percussion  conducted  over  the  front  of  the  chest.  The  absolute 
cardiac  dulness,  below,  owes  its  straight  inner  outline  to  the  sternal  note. 
In  the  same  manner  the  normal  prsevascular  dulness,  above,  assumes  the 
shape  depicted  in  this  Outline  because  this  is  the  shape  of  the  underlying 
sternum  and  manubrium.  It  is  relatively  narrow  below,  and  broadens 
upwards. 

The  prsevascular  dulness  can  sometimes  be  traced  on  either  side  beyond 
the  sternum,  even  in  health.  In  disease  this  extension  may  become  very 
marked.  Usually,  whether  in  health  or  in  disease,  it  is  not  as  great  on  the 
right  as  it  is  on  the  left  side.  A  narrow  vertical  strip  of  dulness  (i  to 
i  inch  wide)  extending  along  the  left  sternal  border,  can  be  recognised  by 
percussion  in  almost  every  instance.     It  is  shewn  in  this  Outline.     The 


FIG.  XXXII. 


A  narrow  strip  is  seen  to  the  left  side  of  the  sternum,  continuing  upwards 
the  outline  of  the  absolutely  dull  area.  This  strip  is  duller  than  the  surfaces 
between  which  it  is  placed,  but  not  absolutely  dull  The  sternal  surface 
yields  partial  dulness  only,  throughout. 


86  CARDIAC   OUTLINES. 

strip  in  question  is  normally  duller  than  the  sternum  ;  and  it  is  found  to  be 
continuous  with  the  area  of  absolute  cardiac  dulness.  For  this  concord- 
ance of  lines  (which  is  invariably  found  by  careful  percussion)  good  ana- 
tomical reasons  exist.* 

The  additional  line  on  the  left  of  the  prsevascular  dulness,  as  well  as  the 
additional  line  seen  in  this  diagram  to  the  right  of  the  cardiac  dulness  are 
both  easily  discovered.  The  surfaces  which  they  define  are  areas  of  sub- 
resonance,  rather  than  of  partial  dulness.  vSansom's  pleximeter  will  be 
found  very  useful  in  tracing  these  boundaries,  as  well  as  in  connection 
with  the  final  stage  of  cardiac  percussion. 

*  The  same  reasons  explain  the  striking  concordance  which  a  good  percussor  invariably 
finds  between  the  lines  which  he  has  traced  from  above  and  those  traced  from  below. 


CARDIAC  OUTLINES.  8/ 


SEVENTH    AND    FINAL    STEP    IN    CARDIAC    PER- 
CUSSION : 

THE      HEPATIC      AND     THE      SUPRAHEPATIC      LINES      AS 
OBTAINED    BY    PERCUSSION. 


We  are  competent  to  find  by  percussion  both  the  hepatic  and  the  supra- 
hepatic  line,  not  only  in  the  right  chest,  but  also  in  the  left.  In  other 
words,  we  can  percuss  out  with  accuracy,  on  the  anterior  surface  of  the  body, 
the  whole  outline  of  the  liver  on  the  one  hand,  and  the  whole  outline  of  the 
heart  on  the  other.* 

Moreover,  we  can  prove  by  percussion  that  these  two  organs  overlap 
from  front  to  back  ;  and  we  are  able  to  trace  the  extent  of  their  overlapping. 
This  is  easily  accomplished,  as  soon  as  their  anatomical  relations,  which 
have  not  always  been  sufficiently  regarded,  are  thoroughly  understood.  In 
the  ordinary  routine  of  physical  examinations  of  the  heart  the  lines  in  ques- 
tion are  best  traced  at  an  earlier  stage  ;  a  different  course  has  been  adopted 
here  to  facilitate  their  demonstration. 


THE   HEPATIC   LINE. 


Let  it  be  stated  once  more  that  the  Suprahepatic  line  marks  the  highest 
level  reached  by  the  liver  in  the  depth  of  the  chest  ;  whilst  the  Hepatic  line 

*  There  is  no  reason  why  an  experienced  percussor  should  not  succeed  in  this  with  un- 
aided finger  percussion.  Nevertheless  Sansom's  pleximeter  is  a  great  help  and  it  was 
with  its  assistance  that  the  author  first  clearly  defined  the  two  lines  in  question  (see 
Lancet^  Aug.  29,  1891). 


^s 


CARDIAC   OUTLINES. 


indicates  the  highest  level  of  actual  contact  between  the  liver  and  the 
anterior  chest-wall  ;  this  being,  at  the  same  time,  the  lowest  level  reached 
by  the  heart.  A  drawing  representing  merely  the  parts  situated  immediately 
behind  the  anterior  chest-wall  would  sliew  the  hepatic  line,  but  it  Mould  not 

shew  the  suprahepatic  line  ;  it 
might  shew  the  lowest  level 
of  the  heart  and  of  the  peri- 
cardial floor  ;  but  it  could  not 
shew  the  highest  level  of  the 
latter. 

The  annexed  illustration  is 
of  this  kind.  In  it  only  the 
foremost  intrathoracic  plane  is 
shewn.  Tlie  suprahepatic  line 
does  uot  tlierefore  come  into 
view. 

The  liver  and  the  heart  being 
not  only  in  contact,  but  partly 
wedged   one   in    front    of    the 
other,    and    both    being   dense 
organs,    it     might   have    been 
very  difficult  (and  is  still  most 
often  alleged  to  be  impossible) 
to  trace  their  mutual  boundar}' 
by  percussion.     But  the  effect 
of   the  gastric  resonance  is  to 
THE  HEPATIC  LINE  IN   ITS    RELATIONS   TO     transform,    in    the  left  half  of 
THE  LUNGS,  INFRASTERNAL  ANGLE,  AND     the  chest,  the  hepatic  duluess 
STOMACH.  into  a  modified    hepatic  reso- 

nance.   Thanks  to  this  circum- 
stance all  difficulty  is  removed. 
A  simple  diagram   will  sliew  more  clearly  than  words  can  explain   how 
the  hepatic  line,   or   anterior   cardio-hepatic  boundary,    can  be   determined 
by  the  ordinary  method  of  contrast  in  })ercussion. 


FTG.   XXXIII. 


CARD/AC  OUTLINES. 


89 


Cardiac  Subres- 
onance 


Cardio-hepatic 
Subresonance 


Cardiac  Dulness 


Cardio-hepatic 

Dulness 


Hepatic  Subres- 
onance 


FIG.  XXXIV. 


Diagram  representing  the  hepatic  line  IIH'  and  the  relative  qualities  of 
the  sounds  obtained  by  percussing  above  and  below  the  line.  Part  of  the 
costal  arch,  the  infrasternal  angle,  and  the  xiphoid  cartilage  are  represented 
in  interrupted  line.  The  arrow  passing  through  the  left  chondroxiphoid 
angle  represents  the  left  edge  of  the  sternum  and  prolongation  of  the 
same  line  downwards. 


The  diagram  shews  that,  whereas  in  the  right  chest  the  hepatic  surface 
below  the  line  HIi'  is  dull,  and  the  cardiac  surface  immediately  above  it, 
comparatively  resonant,  in  the  left  chest  the  hepatic  surface  is  compara- 
tively resonant  and  the  cardiac  surface  above  it  is  absolutely  dull.  We  may 
therefore  feel  quite  certain  that  percussion  will  avail  to  mark  off  the  lower 
boundary  of  the  cardiac  dulness  from  the  dulness  of  the  liver  ;  and  in  view 
of  the  clinical  advantage  which  %ve  may  secure,  we  should  not  neglect  to  put 
to  the  test  our  own  ability  to  carry  out  this  method. 

II.    THE    SUPRAHEPATIC   LINE. 


(The  following  remarks  will  be  more  readily  understood  in  conjunction 
with  Outline  YIII.  which  shews  diagrammatically  the  upper  surface  of 
the  liver  and  the  pericardial  floor,    the   heart   having   been    removed.     It 


90  CARDIAC    OUTLINES, 

will  be  seen  that  the  deep-seated  convexity  of  the  liver  extends  across 
the  chest  as  far  as  the  left  extremity  of  the  organ,  and  is  parallel  with  the 
hepatic  line,  except  at  this  left  extremity,  where  the  liver  becomes  reduced 
in  thickness.) 

In  the  right  inframammary  region  the  pulmonary  resonance  was  found  to 
be  impaired  at  the  level  of  the  5th  cartilage,  and  this  was  ascribed  to  the 
presence,  behind  a  layer  of  lung,  of  the  deep  convexity  of  the  liver. 

Precisely  the  same  influence  might  be  expected  to  obtain  farther  toward 
the  left,  and  it  does  make  itself  felt  there.  Let  us  consider  first  the  partial 
cardiac  dulness  over  the  lower  third  of  the  sternum. 

In  this  situation,  although  the  heart  is  superficial,  yet,  owing  to  resonance 
conducted  by  bone  from  a  distance,  the  dulness  is  not  absolute.  But  where 
the  deep  convexity  of  the  liver  passes  behind  the  lower  part  of  the  prse- 
cordium,  the  presence  of  this  organ  should  be  indicated  by  an  increase  of 
the  dulness  ;  and  if  percussion  of  the  sternum  be  practised  from  above 
downwards,  a  transverse  boundary  should  be  found  in  the  cardiac  area 
between  the  more  resonant  upper  part  or  cardiac  subresonance,  and  the  less 
resonant  lower  part  or  cardio-hepatic  subresonance.  This  is  precisely  the 
result  obtained  by  careful  percussion  ;  and  the  line  will  prove  to  be  an  exact 
continuation  of  the  line  SH  (see  Outline  XXXV). 

Passing  now  to  the  area  of  absolute  cardiac  dulness,  a  difference  in  the 
degree  of  dulness  should  likewise  be  recognisable  between  its  upper  and 
its  lower  district,  the  lower  or  cardio-hepatic  area  being  more  deeply  dull 
by  reason  of  the  combined  cardiac  and  hepatic  dulnesses.  Outline  XXXV. 
shews  this  distinction  in  a  very  accentuated  manner.  AVith  the  help  of  a 
Sansom's  pleximeter  convincing  proof  of  its  reality  can  be  obtained  by  any 
observer. 

Having  once  been  recognised,  the  line  of  demarcation  is  easily  found 
again,  either  in  the  same  subject  or  in  others.  After  having  sought  it 
according  to  the  easier  method,  the  student  will  probably  succeed  in  finding 
it  at  once  in  the  middle  of  the  area  of  absolute  cardiac  dulness,  and  in 
tracing  it  back  from  left  to  right,  until  it  merges  into  the  upper  line  of 
hepatic  dulness,  originally  defined  in  the  right  inframammary  region. 

This  concludes  the  description  of  the  method  and  of  its  normal  results. 
The  ensuing  pages  will  give  some  insight  into  the  application  of  the  method 
to  pathology. 


FIG.  XXXV. 


SH — The  suprahepatic  line,  separating,  on  the  right  side,  subresonance 
above  from  partial  dulness  below,  and,  on  the  left  side,  absolute  dulness  of 
less  degree  above  from  that  of  greater  degree  below.  HX — The  hepatic 
line,  below  which — absolute  hepatic  dulness  on  the  right,  and  modified  he- 
patic resonance  on  the  left. 

gr 


92  CARDIAC   OUTLINES. 

CARDIAC    PERCUSSION     IN    ABNORMAL 
CONDITIONS. 

The  value  of  an  accurate  knowledge  of  the  position  of  the  normal  lines 
of  percussion  will  become  apparent  to  the  clinical  student  in  connection 
with  the  displacements  to  which  they  are  liable  in  disease. 

I. 

THE    PATHOLOGICAL  VARIATIONS    IN    THE    POSITION    OF 
THE  HEPATIC  AND  OF  THE  SUPRAHEPATIC  LINES. 

(i)  Any  abdominal  influence  occasioning  a  uniform  rise  of  the  diaphragm, 
will  raise  both  the  hepatic  and  the  suprahepatic  line  above  their 
average  level. 

(2)  Any  thoracic  influence  occasioning  a  uniform  depression  of  the  dia- 

phragm will  lower  both  these  lines. 

(3)  Any  influence  either  depressing  or  raising  the  diaphragm  on  one  side 

only  will  tilt  one  end  of  the  liver  or  the  other,  and  occasion  an  ob- 
liquity of  the  two  lines. 

(4)  Lastly,  any  alteration  in  the  vertical  thickness  of  the  liver  will  cause 

the  two  lines  to  be  either  nearer  to  each  other,  or  farther  apart. 

II. 

THE  PATHOLOGICAL  VARIATIONS  IN  THE  LEVEL  OF  THE 
HEART,  AND  THEIR  CAUSES. 

The  practical  meaning  of  the  preceding  statements  is  that  any  variation  in 
the  level  of  the  liver  as  a  whole  will  likewise  afifect  the  level  of  the  heart  ; 
and  that,  conversely,  any  rise  or.  fall  in  the  lower  cardiac  level  will  be  bound 
up  with  a  similar  rise  or  fall  of  the  subjacent  hepatic  surface  ;  the  usual, 
although  not  invariable,  result  being  a  change  in  the  direction  of  the  longi- 
tudinal axis  of  the  liver. 

An  unusually  high  position  of  the  heart  is  almost  always  of  pulmonary 
rather  than  of  cardiac  origin  ;  cardiac  atrophy  may,  however,  be  an  occa- 
sional cause.  On  the  other  hand,  the  causes  of  a  displacement  of  the  heart 
downwards  usually  reside  in  the  pericardium  or  in  the  heart  itself,  and 
depend  upon  variations  in  their  volume. 


CARDIAC   OUTLINES.  93 

Roughly  speaking,  an  increase  in  the  size  of  the  heart  may  take  place  in 
one  of  two  directions  : 

The  heart  may  enlarge  in  its  transverse  axis  ; 
It  may  enlarge  vertically. 

The  first  of  these  changes  will  be  recognised  by  a  shifting  of  the  lateral 
boundaries.  The  second  will  lead  to  a  depression  not  only  of  the  lower 
cardiac  boundary  but  also  of  the  left  extremity  of  the  hepatic  line.  The 
natural  declivity  of  the  liver  downwards  and  to  the  left  will  then  be  in- 
creased. This  is  one  of  the  most  striking  results  of  left  cardiac  hyper- 
trophy, whenever  it  attains  considerable  proportions. 

Enlargement  of  the  pericardium  by  fluid  effusions  invariably  depresses 
the  liver.  Cceteris  paribus  the  depression  is  greater  on  the  left  side  than 
on  the  right,  and  the  hepatic  line  assumes  an  obliquity  analogous  to  that 
which  results  from  left  cardiac  hypertrophy. 

CARDIAC    HYPERTROPHY: 

ITS  VARIETIES  AND  ITS  INFLUENCE  ON  CARDIAC 

DULNESS. 

Cardiac  Hypertrophy  may  be  general  or  partial. 

If  partial,  cardiac  hypertrophy  may  affect  the  Right  or  the  Left  side  of  the 
heart. 

I. 

GENERAL  CARDIAC  HYPERTROPHY. 

(i)  If  due  to  healthy  increase  in  the  muscular  and  respiratory  functions, 
the  hypertrophy  will  seldom  be  great.  An  increase  in  total  cardiac  dulness 
may  be  perceived  ;  but  this  will  not  be  considerable,  and  the  liver  will  not 
be  greatly  depressed  nor  the  cardiac  apex  moved  far  outwards. 

(2)  If,  on  the  contrary,  it  be  due  to  adherent  pericardium,  hypertrophy 
may  attain  a  great  size,  and  will  make  itself  known 

(i)  by  much  increased  absolute  dulness, 

(2)  by  outward  and  downward  displacement  of  the  apex  beat,  and 

(3)  by  downward  displacement  of  the  liver. 


94  CARDIAC   OUTLINES. 

II. 
PARTIAL  HYPERTROPHY  LIMITED   TO  THE   RIGHT 

VENTRICLE. 
When  not  complicated  with  dilatation,  this  does  not  appreciably  modify 
the  anatomical  lines  of  percussion.      Hypertrophy  complicated  with  dilata- 
tion will  be  mentioned  farther  on. 

III. 

PARTIAL  hypertrophy'  LIMITED  TO  THE  LEFT 
VENTRICLE. 

This  gives  rise  to  very  definite   results   easily   recognised.       The    apex 

beat  is 

(i)  depressed, 

(2)  displaced  towards  the  left,  and 

(3)  at  the  same  time  very  forcible. 

The  left  extremity  of  the  hepatic  line  is  apt  to  be  depressed  (this  change 
should  be  looked  for  only  in  cases  of  extreme  hypertrophy)  and  may  thus 
become  oblique  downwards  and  towards  the  left  in  a  very  marked  degree. 

CARDIAC  DILATATION  : 
ITS  VARIETIES  AND  ITS  INFLUENCE  ON  CARDIAC 

DULNESS. 

The  subject  of  cardiac  dilatation  might  be   subdivided  into  the  following 

groups  : 

r  without  hypertrophy. 
I.   General  dilatation]  ^general 

of  the  heart,  i       with  hypertrophy       -       or 


(  partial. 
II.   Partial  dilatation  i  "  '  (  of  the  whole  heart. 


(  without  hypertrophy. 


Partial  dilatation  J  f  ot  ttie  whole  tieart. 

of  the  heart  1       ^'^'^  hypertrophy       \  of  the  dilated  side  only, 

i.  (  of  the  other  side  only. 

Since,  however,  the  extent  and  the  direction  of  any  increase  in  dulness 
due  to  this  cause  vary  according  to  the  portion  of  the  heart  which  is  af- 
fected, we  shall  adopt  the  following  subdivision  ; 

I.   General  dilatation. 


CARDIAC  OUTLINES,  95 

j  (a)  limited  to  the  right  auricle. 

II.    Partial  dilatation  -|  ^^^   ^'"^'^^^  *^  "^^  "§^^  ventricle. 

I  (c)  limited  to  the  left  auricle. 

(^(d)  limited  to  the  left  ventricle. 

I. 
GENERAL    DILATATION. 

Seldom  primary,  except  as  a  result  of  anaemia,  general  dilatation  often 
comes  under  observation  at  a  late  stage  of  cardiac  disease,  v^^hen  this  has 
ceased  to  be  complicated  with  much  hypertrophy.  Hearts  in  this  condition 
are  usually  very  bulky,  either  from  the  dilatation  being  general,  or  because 
one  side  still  retains  some  compensatory  hypertrophy. 

II. 
PARTIAL   DILATATION. 

A. — DILATATION    LIMTrED    TO    THE    RIGHT    AURICLE. 

This  dilatation  invariably  throws  the    extreme  right  cardiac   boundary 
.  farther   outwards — not   always,    however,  in    proportion    to  the  increased 
bulk,  since  some  displacement  towards  the  left  may  occur  as  a  result  of 
other  circumstances. 

B. — DILATATION    LIMITED    TO    THE    RIGHT    VENTRICLE. 

Dilatation  of  the  right  ventricle  invariably  throws  the  left  heart,  unless 
bound  down,  farther  outwards,  and  the  liver  slightly  downwards.  The 
cardiac  displacement  predominates  over  the  hepatic  so  long  as  the  heart 
remains,  as  in  health,  freely  movable.  Fig.  XXXVI.  shews  that  the  right 
ventricle  can  expand  with  freedom  only  in  these  two  directions,  its  antero- 
posterior diameter  being  confined  by  unyielding  structures. 

C. — DILATATION    LIMITED    TO    THE    LEFT   AURICLE. 

Dilatation  of  the  left  auricle,  if  considerable,  gives  rise  to  pulmonary 
pressure  symptoms,  but  not  to  any  physical  signs,  except  downward  dis- 
placement of  the  apex  beat. 

D. — DILATATION    LIMITED    TO    THE   LEFT    VENTRICLE. 

This  dilatation  markedly  depresses  the  apex  beat,  with  displacement  out- 
wards. Here,  as  in  c,  the  left  extremity  of  the  hepatic  line  may  be  alone 
pr  chiefly  displaced, 


96  CARDIAC  OUTLINES. 


THE  ENCROACHMENT  ON  THORACIC  SPACE  DUE 

TO    COMBINED    GENERAL    HYPERTROPHY 

AND  DILATATION  OF  THE  HEART. 

Sometimes  the  heart  is  much  hypertrophied  as  well  as  much  dilated. 
When  the  change  is  general  (as  in  some  instances  of  adherent  pericardium 
at  a  late  stage),  the  heart  may  be  very  large.  The  absolute  dulness  is  then 
greatly  increased  above  and  at  the  sides,  and  the  diaphragm  and  the  liver 
may  be  markedly  depressed.  The  resulting  encroachment  on  thoracic 
space  is  specially  noticeable  in  the  relatively  less  capacious  chest  of  chil- 
dren.     This  feature  is  well  shewn  in  the  present  Outline. 


FIG.   XXXVI. 


The  heart  and  liver  are  seen  from  the  left  side  ;  a  vertical  antero-posterior 
section  is  supposed  to  have  been  made  immediately  to  the  left  of  the  heart. 
A— Aorta.  B — Gall  bladder.  D— Diaphragm.  G— Outline  of  stomach. 
J — Vertical  section  through  the  left  extremity  of  the  liver.  H — Level  of  the 
hepatic  line.  SH — Level  of  the  suprahepatic  line.  P — Pulmonary  artery. 
Pc — Outline  of  the  pericardium,  shewing  the  line  of  reflection  from  the  great 
vessels.  L — Left  auricle.  CE — CEsophagus.  R — Right  auricle  and  Vena 
Cava. 


gS  CARDIAC   OUTLINES. 

THE  CHANGES  IN  THE  RELATIONS  OF  PARTS  IN 
PERICARDIAL  EFFUSION  ;  AND  THE  DIAG- 
NOSIS OF  EFFUSION  BY  PERCUSSION. 

Percussion  furnishes  the  positive  element  in  the  diagnosis,  viz.,  increase 
in  the  area  of  prsecordial  dulness  ;  palpation  and  auscultation  furnish  the 
negative  elements,  which  are  diminution  or  loss  of  heart-beat  and  of  heart- 
sounds.  The  methods  of  palpation  and  of  auscultation  are  described  under 
the  corresponding  headings. 

The  changes  in  the  prsecordial  dulness  discovered  by  percussion  are  : 

Alterations  in  shape. 
Alterations  in  size. 
Alterations  in  quality. 

Their  extent  will  vary  with  the  amount  of  fluid  effused,  the  recognition 
of  a  moderately  large  effusion  presenting,  as  a  rule,  no  difficulty. 

(i)  When  percussed,  the  pericardial  enlargement  is  found  to  be  of  a 
typical  shape.  The  dull  area  is  broad  at  the  base  and  tapers  more  or  less 
evenly  towards  the  manubrium  sterni. 

In  considerable  effusion  the  peaked  summit  will  be  exchanged  for  a  more 
or  less  spherical  outline  of  the  upper  border  of  dulness  ;  the  lower  border 
remaining,  as  before,  rectilinear.  Outline  XXXVII.  represents  a  stage 
between  the  peaked  and  the  globular  form. 

(2)  The  alteration  in  the  extent  of  absolute  dulness  is  apt  to  be  under- 
valued owing  to  the  conducted  resonance  of  the  sternum  and  to  the  over- 
lapping of  the  fringe  of  the  lung  in  front  of  the  effusion  ;  but  some  dulness 
always  extends  at  least  as  far  as  the  right  sternal  border. 

(3)  The  quality  of  the  dull  note  is  characteristic.  There  is  "  deadness" 
or  complete  absence  of  elastic  as  well  as  of  sonorous  vibration  over  the 
dull  area.      This  sign  is  an  important  help  in  all  doubtful  cases. 

The  Outline,  which  has  been  constructed  on  the  basis  of  clinical  cases 
observed,  displays  : 

The  shape  of  the  distended  pericardium  : 

(a)  This  is  always  broader  at  the  base, 

(b)  In  small  effusions,  pyriform, — the  normal  shape  of  the  prae- 

cordium  exaggerated  ; 

(c)  In  large  effusions  almost  hemispherical. 


FIG.   XXXVI L 


Pc  and  Pc' — Right  and  left  pleuro-pericardial  layer,  distended  by  fluid. 
P  and  P' — Pleural  layer  continued  upwards  from  the  pleuro-pericardium. 
Sc  and  So' — Right  and  left  subclavian  artery.  C  and  C — Right  and  left 
carotid.  SH — Upper  surface  of  the  liver,  depressed  and  moulded  by  the 
v/eight  of  the  distended  sac. 

99 


lOO  CARDIAC   OUTLINES, 

The  predominance  of  pericardial  dilatation  towards  the  left.  This 
usually  causes  a  bulging  of  the  left  side  of  the  chest,  which  is 
not  shewn  here. 

The  much  increased  vertical  diameter. 

The  downward  bulge  of  the  floor  of  the  pericardium. 

The  depression  of  the  liver. 

The  symmetrical  depression  of  the  diaphragm, — causing  depres- 
sion of  the  stomach,  and,  to  a  less  extent,  of  the  spleen. 

The  great  increase  in  the  absolute  praecordial  dulness. 

The  slighter  increase  in  the  absolute  hepatic  dulness  (which  is  dis- 
placed). 

The  much  extended  line  of  contact  between  prascordial  and  hepatic 
dulnesses,  which  are  nevertheless  perfectly  distinguishable  from 
one  another  by  percussion. 


THE  HEART  IN  PERICARDIAL  DROPSY. 

This  Outline  is  based  upon  measurements  taken  after  death  in  a  case  of 
Pericarditis.^  The  heart  is  displayed  as  it  lies  in  the  middle  of  the  effusion. 
The  points  specially  to  be  noted  are  : 

(i)  The  distension  of  the  pericardial  sac  ; 

(2)  The  central  and  isolated  position  of  the  heart  surrounded  by  fluid  ; 

(3)  The  interval  between  the  lower  anterior  border  of  the  heart  and  the 

floor  of  the  pericardium,  Pc  ; 

(4)  The  stretching  of  the  heart  and  of  the  large  vessels  (especially  in  the 

orthopnoeic  posture,  which  is  the  rule  in  large  effusions)  ; 

(5)  The  depression  of  the  floor  of  the  pericardium  (in  this  case,  as  far  as 

the  level  of  the  tip  of  the  xiphoid  cartilage) ; 

(6)  The  depression  of  the  liver  to  the  same  extent ; 

(7)  Lastly,  not  so  well  shewn  as  in  the  Outline  XXXVII.,  the  lateral 

bulging  of  the  lower  part  of  the  sac  on  either  side  of  its  attach- 
ment to  the  midriff. 
It  will  be  noticed  that  a  cardiac  impulse  perceived,  say  in  the  5th  inter- 
space, would  not  coincide,  as  in  the  normal  subject,  with  the  lower  limit 
of  praecordial  dulness,  but  would  be  decidedly  higher  than  that  line. 

^  A  sketch  of  the  pericardium  in  situ  was  taken  by  Dr.  H.  B.  Grimsdale,  whose 
valuable  assistance  the  author  is  happy  to  acknowledge. 


FIG.   XXXVIII. 


The  shaded  surface  represents  the  distended  pericardium,  imagined  to 
be  transparent  and  to  allow  the  outline  of  the  heart  to  be  seen.  Most  of  the 
letters  have  the  same  meaning  as  in  Outline  XXXVII.  SH — The  supra- 
hepatic  line.  HH' — The  hepatic  line,  and  DD'  the  floor  of  the  pericardium, 
normally  contiguous  with,  but  here  separated  by  fluid  from,  the  anterior  lower 
border  of  the  heart.  At  Pc  the  floor  of  the  pericardium  is  seen  to  be 
depressed,  at  its  point  of  greatest  convexity  downwards,  as  far  as  the  level  of 
the  extremity  of  the  xiphoid  cartilage. 

lOI 


PART  V. 

CARDIAC    AUSCULTATION    IN    THE    NORMAL 

SUBJECT  AND  IN  PATHOLOGICAL 

CONDITIONS. 

It  is  essential  that  the  beginner  in  cardiac  auscultation  should  refresh  his 
memory  as  to  the  anatomy  of  the  heart,  and  particularly  of  the  heart  valves. 
The  next  few  illustrations  are  devoted  to  this  object.  The  two  first  shew 
the  relation  of  the  valves  to  each  other ;  those  that  follow  deal  with  their 
relation  to  the  anterior  chest  wall,  and  with  their  topography. 

The  Clinical  Outlines  belonging  to  this  series  deal,  in  the  first  place,  with 
the  normal  heart-sounds  and  Math  the  situations  in  which  they  are  severally 
audible  ;  and  inasmuch  as  a  graphic  representation  of  the  heart-sounds  is 
sometimes  desirable,  a  code  of  suitable  symbols  has  been  devised. 

The  abnormal  sounds  or  "  murmurs"  may  also  with  advantage  be  ex- 
pressed by  symbols,  and  a  set  of  these  is  suggested  for  use  at  the  bedside. 

Separate  Outlines  are  devoted  to  the  description  of  the  several  murmurs 
with  reference  to  their  site  of  intensity  and  to  their  area  of  conduction. 

The  auscultatory  features  of  pericarditis  form  the  subject  of  a  short  de- 
scription, and  a  passing  reference  is  made  to  aneurysm  of  the  aorta. 


103 


104 


CARDIAC  OUTLINES. 


THE   HEART    VALVES   SEEN   FROM  BELOW. 

The  Outline,  sketched  from  a  dried  specimen,  represents  a  transverse 
section  through  the  upper  third  of  both  ventricles.  It  aims  at  shewing  the 
four  valves  in  their  mutual  relations,  as  viewed  from  below — that  is,  from 
the  ventricular  aspect. 

FIG.  XXXIX. 


A.M 

A. 

L.P. 

R.P. 

P. 

R. 

V.D. 

V.S. 

s. 

The  anterior  mitral  flap,  and  next  to  it  the  posterior  mitral  flap. 

The  anterior  aortic  flap  (in  the  right  ventricle  A  shews  the  surface 
corresponding  to  this  flap). 

A  portion  of  the  left  posterior  aortic  flap. 

The  surface  corresponding,  in  the  right  ventricle,  to  the  right  pos- 
terior aortic  flap,  which  is  not  itself  in  view. 

A  portion  of  the  posterior  pulmonary  flap. 

A  portion  of  the  right  anterior  pulmonary  flap. 

The  left  anterior  pulmonary  flap  is  not  in  view. 

The  tricuspid  valve  is  fully  displayed,  but  is  not  lettered. 

The  right  ventricle  in  section. 

The  left  ventricle. 

The  septum  between  the  ventricles. 


CARDIAC  OUTLIMES. 


105 


THE  VALVES  SEEN  FROM  ABOVE. 

This  is  a  view  of  the  same  specimen  as  in  Fig.  XXXIX.,  taken  from 
above — that  is,  from  the  auricular  aspect. 

FIG.  XL. 


A.S. 

A.L. 

P.M. 

A.M 

P.  A. 

L. 

R. 

P.P. 

Ao. 

CD. 

A. 
L.P. 

S.,S, 


The  left  auricular  appendix  in  section. 

The  right  auricular  appendix. 

The  posterior  mitral  flap. 

The  anterior  mitral  flap. 

The  pulmonary  artery. 

The  left  anterior  pulmonary  flap. 

The  right  anterior  pulmonary  flap. 

The  posterior  pulmonary  flap. 

The  aorta, 
and   C.S.    The  right  and  the  left  Coronary  Arteries,  with  their  ori- 
fices in  the  Sinuses  of  Valsalva. 
The  anterior  aortic  flap, 
and    R.P.    The  left  and  the  right  posterior  aortic  flaps. 
,  S.,   The  interventricular  septum  distantly  seen  between  the  aortic 
flaps,  and  through  the  transparent  membrane  of  the  tricuspid 
valve. 


I06  CARDIAC  OUTLINES. 


THE  SITES  OF  THE  VALVES  PROJECTED  TO  THE 
ANTERIOR    SURFACE    OF    THE    CHEST. 

(The  dermographic  method  does  not  attempt  to  indicate  the  exact  situa- 
tion of  the  several  valves  within  the  chest,  but  merely  their  projection. 
The  grouping  of  lines  which  results  is  unreal — in  the  same  way  as  the 
grouping  of  stars,  such  as  it  appears  to  the  human  eye,  is  unreal.  The 
projection  is  nevertheless  a  help. 

The  valves  appear  as  mere  lines  ;  this  also  is  a  result  of  the  projection.) 

HOW  TO  "PLACE"  THE  VALVES  IN  THE  PROJECTION. 
THE  LEFT  THIRD  CARTILAGE  AS  A  LANDMARK. 

Outlines  XIV.  to  XVII.  shew  how  the  projection  of  the  semilunar  valves 
can  be  localised  by  drawing  a  line  (ML)  from  the  middle  point  of  the 
sternum  to  the  left  2d  chondrocostal  junction.  A  more  rapid  guide,  as 
accurate  as  the  subject  will  admit  (for  individual  varieties  are  common),  is 
the  left  3d  chondrosternal  junction.  The  horizontally  arranged  pulmonary 
semilunars  follow  the  upper  line  of  the  cartilage,  lying  either  a  little  way 
above  or  just  below  this  line,  and  chiefly  to  the  left  of  the  sternum.  The 
aortic  semilunars  cross  the  junction  obliquely  and  lie  chiefly  under  the  left 
half  of  the  width  of  the  sternum.  The  projection  of  the  mitral  valve  is 
also  connected  with  the  3d  cartilage.  Beginning  at  its  inferior  border 
about  \  inch  exterior  to  the  sternum,  it  crosses  the  3d  interspace  obliquely 
downwards  and  inwards  and  ends  behind  the  sternum  at  the  level  of,  and 
close  to,  the  4th  chondrosternal  junction. 

The  projection  of  the  tricuspid  is  the  only  one  not  connected  with  the 
3d  left  cartilage.  It  lies  behind  the  sternum  near  its  right  border,  in  a 
nearly  vertical  line,  extending  from  the  level  of  the  4th  to  the  upper  level 
of  the  6th  cartilage. 


FIG,   XLI, 


The  three  horizontally  placed  dots  indicate  the  position  of  the  pulmo- 
nary semilunar  valve.  The  aortic  valve  forms  an  angle  with  the  latter.  The 
tricuspid  valve  is  represented  by  the  vertical  line.  The  mitral  valve  by  the 
oblique  line  lying  across  the  third  left  interspace. 

107 


I08  CARDIAC  OUTLIN-ES. 

THE  TOPOGRAPHY  OF  THE  SEMILUNAR 

VALVES. 

I.   THE  PULMONARY  VALVE. 

Leaving  aside  the  surface  markings,  we  shall  now  consider  the  relations 
of  the  valves  within  the  chest. 

(i)  The  Pulmonary  Artery  lies  vertically  behind  the  left  2d  interspace  ; 

(2)  It  is  covered  only  by  a  thin  edge  of  lung,  and  by  the  serous  mem- 

brane ; 

(3)  It  is  overlapped  on  either  side  by  the  tip  of  the  auricular  appendices  ; 

(4)  Its  segments  lie  obliquely  across  a  line  ML,  uniting  the  appendices 

(the  bi-appendix  line). 

(5)  Its  flaps  are  known  as  :   The  right  anterior  flap,  AP, 

The  left  anterior  flap,  AP, 
The  posterior  flap. 

(6)  The  line  of  attachment  of  the  posterior  flap  slightly  overlaps  (at  an 

angle)  the  line  of  attachment  of  the  anterior  aortic  flap. 

II.  THE  AORTIC  VALVE. 

(i)  The  origin  of  the  Aorta  corresponds  with  the  left  3d  (inferior)  chon- 
drosternal  angle,  and  with  the  adjoining  surface  of  the  sternum. 

(2)  Its  inclination  is  shewn  in  the  Outline  ; 

(3)  It  is  separated   from   the   sternum  by  the   Pulmonary  Artery,   with 

which  its  anterior  surface  is  intimately  connected. 

(4)  The  Aortic  Valve  lies  almost  exactly  in  the  oblique  line  ML  passing 

through  the  two  auricular  appendages. 

(5)  Its  flaps  are  known  as  :    The  anterior  flap,  AS, 

The  right  posterior  flap, 
The  left  posterior  flap. 

(6)  At  its  right  corner  the  anterior  flap,  AS,  crosses  the  line  of  attachment 
of  the  posterior  pulmonary  flap.' 

^  The  two  vessels  being  at  this  spot  adherent  to  each  other,  it  is  almost  impossible,  in 
opening  the  heart,  to  cut  through  both  of  them  without  damaging  either  one  or  the  other 
of  the  two  flaps  just  mentioned. 


FIG.   XLII. 


AP — The  two  anterior  pulmonary  valve  flaps.     AS — In  dotted  line  the 
anterior  aortic  semilunar  valve  flap. 


log 


no  CA RDIA C   OU TUNES. 


THE  TOPOGRAPHY  OF  THE  AURICULO-VEN- 
TRICULAR  VALVES. 

I.    THE  TRICUSPID  VALVE. 

This  valve  is  relatively  superficial,  since  the  right  auriculo-ventricular 
groove  lies  immediately  behind  the  front  wall  of  the  chest.  The  long 
diameter  of  the  valve  is  almost  vertical ;  but  its  upper  extremity  is  rather 
more  deeply  placed  than  the  lower. 

Its  right,  left,  and  inferior  flaps  surround  an  oblong  or  oval  orifice. 
The  passage  through,  or  the  axis  of,  this  orifice  has  an  almost  transverse 
direction,  from  left  to  right. 

II.    THE  MITRAL  VALVE. 

This  is  the  most  deeply  situated  of  all  the  heart-valves.  It  occupies  the 
most  remote  corner  of  the  left  ventricle,  posterior  to  and  somewhat  to  the 
left  of  the  aortic  orifice. 

Its  long  anterior  flap  is  continuous  with  the  fibrous  aortic  ring  ;  its 
posterior  flap  is  attached  to  the  posterior  part  of  the  left  auriculo-ventricular 
ring.  The  axis  of  this  orifice  has  a  direction  downwards,  forwards,  and  to 
the  left. 

Its  long  diameter  is  not  parallel  with  the  anterior  chest  wall,  and  cannot 
be  projected  on  to  the  latter  without  foreshortening.  This  explains  why 
its  projection  should  be  so  much  shorter  than  that  of  the  Tricuspid  Valve. 


FIG.  XLIII. 


S— The  septum  cut  down,  affording  a  view  into  the  left  ventricle  as 
well  as  into  the  right.  M — The  anterior  mitral  flap,  behind  which  is  seen  a 
portion  of  the  posterior  flap.  T — The  inferior  flap  of  the  tricuspid  ;  the 
right  and  the  left  flap  are  also  in  view. 


III 


AUSCULTATION    SERIES. 


THE  PRINCIPLES  AND  THE  METHOD  OF  CARDIAC 

AUSCULTATION. 

Cardiac  Auscultation  has  three  objects  for  study  : 

(i)  The  normal  heart-sounds  and  their  peculiarities, 

(2)  The  pathological  variations  of  the  normal  heart-sounds. 

(3)  The  abnormal  sounds  known  as  "  Bruits  "  or  "  Murmurs." 

In  other  words,  a  clinical  report  of  the  auscultation  of  any  heart  implies 
answers  to  the  following  questions  : 

(A)  Are  the  heart-sounds  in  any  way  peculiar  without  being  abnormal  ? 

(B)  Are  the  heart-sounds  abnormal  ? 

(C)  Are  they  accompanied  by,  or  replaced  by,  any  murmurs  ? 

It  is  part  of  the  scheme  of  the  graphic  method  to  record  these  observa- 
tions on  a  suitable  thoracic  Outline,  by  means  of  symbols.  The  symbols 
should  be  absolutely  clear  and  unequivocal. 


The  beginner  should  be  made  to  listen  at  first  to  absolutely  normal 
heart-sounds,  in  subjects  possessing  a  strong  heart's  action.  At  this  stage 
he  should  practise  "  timing"  the  first  and  the  second  sound,  by  comparing 
their  time  with  that  of  the  apex-beat  or  of  the  carotid  beat.  Neglect 
of  this  essential  detail  of  practical  training  accounts  for  the  greater  part  of 
subsequent  difficulties  and  delays. 


112 


•  ,^  CARDIAC  OUTLINES.  II3 

The  student's  attention  may  be  then  called  to  the  more  striking  varieties 
of  the  heart-sounds,  such  as  the  loud,  the  feeble,  and  the  reduplicated 
sounds. 

His  next  objects  for  study  should  be  the  simple  valvular  murmurs  ;  and 
murmurs  should  be  selected  for  him  well  defined  and  easily  heard.  These  he 
should  practise  "  timing,"  that  is,  referring  to  the  systolic  or  the  diastolic 
period  of  the  heart's  cycle. 

After  the  simple  murmurs  he  should  be  made  to  study  those  of  more 
complex  rhythm.  The  timing  of  these  is  often  a  matter  of  difficulty  even 
for  trained  observers.  The  following  method  is  useful  as  a  means  of 
avoiding  confusion  when  the  heart's  rhythm  is  misleading  and,  as  it  were, 
inverted  : 

Find  the  systolic  time  by  carefully  feeling  the  heart's  impulse,  or  that  of 
the  carotid  artery  ;  and  beat  time  to  this  with  the  foot  or  with  the  finger. 
Auscultation  of  the  doubtful  sounds  should  then  be  performed  whilst  the 
observer  continues  beating  time. 

In  some  cases  of  loudly  accentuated  second  sound,  it  may  be  easier  to 
beat  the  diastolic  instead  of  the  systolic  time,  and  to  time  the  murmurs 
accordingly. 


114  CARDIAC  OUTLINES. 

THE   HEART-SOUNDS. 

SUGGESTED  CODE  OF  SYMBOLS  FOR  THE  NORMAL  HEART- 
SOUNDS  AND  FOR  THEn<.  PATHOLOGICAL 
VARIATIONS. 

(For  the  advanced  student.) 
(a)  the  normal  heart-sounds. 

The  first  Sound  being  relatively  long  has  sometimes  been  figured  thus 
■^  and  the  second  shorter  Sound  thus  ^^-^. 

The  author  has  adopted  this  notation  as  the  basis  of  an  easy  code  of 
Symbols. 

I. 

Inasmuch  as  a  first  sound  is  produced  both  at  the  Mitral  and  at  the 
Tricuspid  Valves,  and  a  second  sound  both  at  the  Aortic  and  at  the  Pul- 
monary Valves,  each  of  these  may  be  conveniently  described  by  coupling 
wilh  the  sign  for  the  First  Sound  (■="■),  or  with  the  sign  for  the  Second 
Sound  (^^),  the  initial  letter  of  the  Valve, 

For  instance,  the  Mitral  First  Sound  would  be  expressed  thus  : 

]M 

and  the  Aortic  second  sound  thus  ; 

IL 

Should  the  sounds  happen  to  be  weak  or  heard  distantly,  this  may  be 
readily  expressed  by  substituting  small  characters  and  thinner  lines  for  the 
capitals  and  for  the  thick  lines  ;  for  instance,  a  weak  Mitral  ist  Sound 
would  be  written  thus  : 

m 

Sounds  so  weak  as  to  be  almost  inaudible  might  be  expressed  by  dotted 
symbols. 


FIG.  XLIV. 

SYMBOLS     FOR    NORMAL    HEART-SOUNDS. 

I 

I,    tL    ^    ^ 

II 

III 
T^    M&    T^     M^ 

lA  tZ   viA  2:^3 


TA   T3    NA    MJB 


"irn^ 


I — The  four  heart-sounds  when  heard  loudly,  II — The  four  heart- 
sounds  when  he^rd  feebly  (the  dotted  lines  indicate  very  feeble  sounds). 
Ill — The  combination  of  a  loud  first  sound  with  a  feeble  second  sound. 
IV — The  combination  of  a  feeble  first  with  a  loud  second  sound.  V — The 
first  sound  and  the  second  both  equally  loud. 


J15 


Il6  CARDIAC  OUTLINES. 


III. 


If  a  loud  Mitral  1st  sound  should  be  followed  by  a  loud  Aortic  2d  sound 
two  signs  from  the  first  series  would  be  used.  If  one  of  the  sounds  should 
be  weak  and  the  other  strong,  this  could  be  symbolised  by  combining  a 
sign  from  the  first  with  a  sign  from  the  second  series,  thus  : 

Ma     and     m    A 

(b)  individual  peculiarities  of  the  normal  heart-sounds. 

Heart-sounds  differ  as  do  the  voices  of  individuals — or  their  features. 
These  differences  can  be  described,  or  delineated,  but  it  is  quite  impossible 
to  express  them  by  means  of  symbols.  It  would  be  premature  for  the 
junior  student  to  attempt  to  study  them.  To  the  advanced  student  and 
to  the  physician  they  spontaneously  become  more  and  more  obvious,  with 
increasing  experience  and  power  of  observation. 

(c)  pathological  variations  in  the  normal  heart-sounds^ 

These  variations  relate  to  : 

(i)  Pitch  and  "  timbre," 

(2)  Time  or  duration, 

(3)  Loudness, 

(4)  Uncoupling  or  reduplication, 

(5)  Accentuation. 

(i)  Pitch  and    "timbre"   must   be    described    in   words;    they   are    not 
easily  symbolised. 

(2)  The  same  remark  applies   to  time   or  duration,    although,   without 

introducing  any  fresh  symbols,  diagrams  could  be  arranged  dis- 
playing the  normal  series  of  the  heart-sounds,  and  any  series  of 
abnormally  long  or  abnormally  short  sounds,  or  lastly,  of  sounds 
separated  by  abnormally  short  or  long  intervals. 

(3)  As  regards  loudness,  a  suggestion  has  been  made  as  to  the  mode  of 

registering  relative   differences,    such   as   occur  in   normal    cases, 


FIG.   XLV. 
SYMBOLS    FOR    REDUPLICATED    HEART-SOUNDS. 


i    M     ^    <4 


II 


i    s    <i     i^ 


III 


Xt  M^  X^  M>2 


IV 


s=^^      =^        e=siQ?        »^^ 


I — Reduplication  of  sounds  with  loudness.  II — Reduplication  without 
loudness.  Ill — Reduplication  and  loudness  of  first  sound  with  feebleness 
of  second  sound.  IV — Reduplication  of  both  sounds  and  loudness  of  the 
second  sounds. 


117 


Il8  CARDIAC  OUTLINES. 

The  sound  may,  however,  be  unusually  loud,  or  feeble.  A  special 
notation  is  then  required  ; 

Excessive  loudness  can  easily  be  represented  by  increasing  the 
size  of  the  capital  letter,  and  the  thickness  of  the  line. 

Extreme  feebleness  may  be  conveniently  expressed  by  iising  a 
dotted  or  interrupted  line,  beneath  a  small  letter  (see  Fig.  XLIV.). 

REDUPLICATION    OF    HEART-SOUNDS. 

(4)  The  most  common  variation  in  time  is  relative  delay  or  hurry  of  some 
constituent  of  the  normal  sounds.  Each  of  the  so-called  heart- 
sounds  being  a  blend  of  two  sounds,  delay  or  hurry  of  one  of  them 
leads  to  a  breaking  up  of  the  composite  sound  into  two, — or,  as  it 
is  termed,  to  a  reduplication  of  the  sound. 

Reduplications  can  be  expressed  by  a  very  simple  device — Let 
the  line  below  the  letter  be  repeated,  as  for  instance  in 


This  symbol  will  signify,  according  to  the  code  proposed,  re- 
duplication of  the  Aortic  Second  Sound. 

ACCENTUATION    OF    HEART-SOUNDS, 

(5)  Loudness  and  accentuation  are  most  commonly  associated,  but  they 
are  not  identical.  A  sound  may  be  loud  without  that  sharpness 
of  delivery  which  we  understand  by  accentuation.  On  the  other 
hand,  it  is  not  uncommon  for  a  heart-sound  to  lack  loudness, 
whilst  preserving  a  marked  accent.  The  various  combinations 
capable  of  arising  and  the  mode  of  registering  them  are  displayed 
in  the  accompanying  illustration. 


Fia  XLVI. 
SYMBOLS     FOR    ACCENTUATED     HEART-SOUNDS. 


A 


II 

i'       m'      y'      m: 


III 


Xi  Mi  xi    m'^ 


IV 


IA'  i^'  !!^A'  ziisE' 


V 

i^  x^  ma'  Mi 

I — Accentuation  and  loudness  of  heart-sounds.  II — Accentuation  and 
feebleness  of  heart-sounds.  Ill — Accentuation  and  loudness  of  the  first 
sound,  the  second  being  feeble.  IV — Accentuation  and  loudness  of  the 
second  sound,  the  first  being  feeble.  V — Accentuation  and  loudness  of  both 
sounds. 


119 


I20  CARDIAC  OUTLINES 


WHERE    TO    LISTEN    FOR    THE  NORMAL  HEART- 
SOUNDS. 

The  normal  heart-sounds  may  be  heard  over  the  whole  praecordium  ;  not, 
however,  with  equal  intensity.  Each  sound  is  heard  most  plainly  over  a 
definite  area,  and,  as  a  rule,  in  the  vicinity  of  the  valve  concerned  in  its 
production.  The  Outline  shews  the  sites  generally  admitted  to  be  the 
most  favourable  for  auscultation  of  the  normal  sounds  ;  they  will  not  require 
any  description.  The  areas  are  more  or  less  contiguous  with  the  anterior 
projection  of  the  valves  :  to  this  rule  there  is  a  striking  exception,  that  of 
the  Mitral  valve.  The  Mitral,  being  deeply  situated,  is  auscultated  at  the 
only  spot,  the  heart's  apex,  where  the  left  ventricle  is  superficial,  although 
the  distance  from  the  valve  is  equal  to  the  length  of  the  ventricle.  The 
aortic  sound  is  also  listened  for  at  a  slight  distance  from  the  aortic  valve, 
in  the  right  2d  interspace,  which  is  for  that  reason  known  as  the  aortic 
interspace.  The  aortic  valve  is  somewhat  deeply  situated  behind  the  origin 
of  the  pulmonary  artery. 


FIG.  XLVII. 


The  sites  of  the  valves  projected  to  the  anterior  chest-wall  are  shewn  as 
in  a  previous  Outline.  Ma — The  site  of  loudness  of  the  mitral  first  sound. 
Ta — The  site  of  loudness  of  the  tricuspid  first  sound.  mA — The  site  of 
loudness  of  the  aortic  second  sound.  niP — The  site  of  loudness  of  the  pul- 
monary second  sound. 

121 


122  CARDIAC   OUTLINES. 


CARDIAC   AUSCULTATION    IN    PATHOLOGICAL 

CONDITIONS. 

THE    GRAPHIC    METHOD   APPLIED    TO    THE    STUDY   OF 
CARDIAC    MURMURS  OR  BRUITS. 

The  investigation  of  cardiac  murmurs  needs  much  time  ;  so  does  also  the 
recording  of  results.     The  graphic  method  has   the  advantage  of  saving 
some  of  the  time  otherwise  taken  up  in  describing  the  examination  ;  it  also 
tends  to  promote  accuracy  and  completeness  in  examining  the  heart, 
(i)  Which  is  the  valve  affected  ?   ■ 

(2)  Where  is  the  murmur  best  heard  ? 

(3)  Where  does  it  cease  to  be  heard  ? 

These  questions  must  be  answered  in  all  cases  where  a  murmur  is  audible  ; 
and  the  answers  are  capable  of  being  recorded  graphically. 

The  nature  and  the  site  of  intensity  may  be  expressed  by  any  code  of 
symbols,  provided  the  symbols  are  unequivocal.  A  code  of  this  kind  will 
be  presently  set  forth. 

A  graphic  representation  of  the  area  of  conduction  of  murmurs  generally 
takes  place  by  means  of  shadings. 

For  quick  work  the  simplest  of  all  thoracic  Outlines  (Fig.  I.)  is  the  most 
useful  ;  but  whenever  accurate  and  searching  observations  have  to  be  made, 
Outlines  are  required  shewing  the  ribs  and  interspaces.  It  should  be 
understood,  however,  that  Outlines  of  this  sort  are  not  serviceable  unless 
fairly  correct  anatomically,  and  of  good  size. 

Most  cardiac  murmurs  being  valvular,  it  is  important  that  the  normal 
situation  of  the  valves  should  be  present  to  the  mind  of  the  auscultator. 
With  that  view  in  all  the  Outlines  of  the  present  series  the  valve  sites  have 
been  displayed  in  addition  to  the  murmurs. 


CARDIAC   OUTLINES. 


123 


FIG.  XLVIII. 

CODE  OF  SYMBOLS  FOR  THE  NOTATION  OF 
VALVULAR  MURMURS. 


A 


■11 


III 


i 

IV 


V 


VI 


VII 


VIII. 


I — Onward  aortic  murmur.  II — Regurgitant  aortic  murmur.  Ill — 
Regurgitant  mitral  murmur.  IV — Onward  mitral  murmur  (with  thrill 
limited  to  the  apex).  V — Regurgitant  tricuspid  murmur.  VI — Onward 
tricuspid  murmur.  VII — Onward  pulmonary  murmur.  VIII — Regurgitant 
pulmonary  murmur. 


The    following  modifications  may  with  advantage  be  made  in  the  old 
method  of  figuring  bruits  by  arrows  : 

(i)  The  direction  of  the  arrow  must  invariably  indicate  the  direction  of 
the  blood-stream  producing  the  bruit. 

(2)  The    arrow  should   be  provided   with    a  letter    denoting    the    valve 

implicated. 

(3)  If  there  be  any  thrill  this  may  be  symbolized  by  a  waviness  of  the 

arrow. 

(4)  Loudness  of  the  murmur  may  be  expressed  by  increasing  the  thickness 

of  the  arrow  ;  softness  of  the  murmur,  by  using  a  thin  arrow  or 
one  with  dotted  line. 
With  these  precautions  several  arrows  may  be  used  in  the  same  Outline 
without  fear  of  confusion,  to  denote  the  presence  of  different  murmurs. 


124  CARDIAC  OUTLINES. 

LIST  OF  THE  CARDIAC  VALVULAR  MURMURS. 

Valvular  murmurs  may  be 

(1)  Organic  (clue  to  structural  change  in  the  valves  or  orifices)  ;  or 

(2)  Functional  (due  to  faulty  action  of  the  muscles  connected  with  the 

valves   or   orifices  ;    or   to    faulty    quantity   or   quality    of   blood 
(haemic  murmurs). 

THE    FUNCTIONAL    MURMURS. 

The  murmurs  usually  admitted  to  be  functional  are  systolic  in  time,  and 
aortic  or  pulmonary  in  site.  They  are  generally  considered  to  be  hsemic 
in  origin. 

The  pulmonary  haemic  murmur  is  the  most  common  of  all  murmurs. 

THE    ORGANIC    MURMURS. 

The  way  through  any  of  the  orifices  may  be  constricted  (Stenosis)  ;  or, 
a  passage  may  be  left  by  an  inadequate  valve  at  a  time  when  the  orifice 
should  be  closed  (Reflux),      Murmurs  may  therefore  be  produced, 

By  stenosis  of  :  By  reflux  through  : 

(i)  The  tricuspid  orifice.  (5)  The  tricuspid  orifice. 

(2)  The  pulmonary  orifice.  (6)  The  pulmonary  orifice. 

(3)  The  mitral  orifice.  (7)  The  mitral  orifice. 

(4)  The  aortic  orifice.  (8)  The  aortic  orifice. 

Of  these  eight  varieties  the  first,  the  second,  and  the  sixth  are  relatively 
infrequent.  The  others  occur  with  considerable  frequency  and  are  de- 
scribed in  the  following  Outlines. 

It  is  important  to  realize  that  many  of  the  murmurs  commonly  described 
as  valvular,  are  really  "  orificial."  This  is  especially  the  case  with  the 
functional  group  of  valvular  murmurs.  Any  valvular  opening  may  become 
imperfect  either  through  defect  in  the  valve  or  through  defect  in  its  sur- 
roundings. A  door  for  instance  may  fail  to  exclude  draughts,  either 
because  damaged  in  itself,  or  if  sound,  because  its  framework  has  ceased 
to  fit  it.  In  the  heart  also  an  orifice  may  be  at  fault,  and  a  murmur  be 
set  up  without  any  defect  in  the  valve. 


CARDIAC  OUTLINES,  1 25 


THE    SITES    FOR    THE     AUSCULTATION    OF    THE 
CARDIAC    MURMURS. 

SYSTEMATIC    EXAMINATION    OF    THE    HEART    FOR 

MURMURS. 

Before  a  heart  can  be  pronounced  free  from  murmurs,  either  the  entire 
praecordium  must  be  auscultated  inch  by  inch,  or  else  its  examination  must 
be  systematically  localised  to  definite  spots  specially  favourable  for  the  rec- 
ognition of  murmurs.  The  position  of  the  apex-beat  is  supposed  to  have 
been  previously  identified  by  palpation  or  by  auscultation.  The  sites  for 
auscultation  are  six  in  number  and  include,  in  addition  to  the  areas  which 
have  already  been  assigned  for  the  auscultation  of  the  normal  sounds,  the 
mid-sternum^  and  lastly  the  3(3!' and  /\th  left  inter  spaces  in  the  parasternal  line 
which  it  is  convenient  to  term  collectively  the  "  Ventricular  Site,"  this 
area  being  the  centre  of  the  anterior  projection  of  the  ventricular  portion 
of  the  heart.     Thus  the  stethoscope  will  have  to  be  applied  in  succession  to  : 

(i)  The  apex  for  mitral  murmurs, 

(2)  The  right  2d  interspace  close  to  the  sternum  for  aortic  murmurs, 

(3)  The   left  2d  interspace   for  pulmonary   murmurs,   and  for  Naunyn 

and  Balfour's  murmur, 

(4)  The  lower  end   of  the  sternum   for  tricuspid  murmurs,   and  also  for 

aortic  regurgitant  murmurs. 


126  CARDIAC  OUTLINES, 


THE  SITES  FOR  AUSCULTATION— C^/^/////^^^/. 

(5)  The  mid-sternum  for  tricuspid,   for    pulmonary,   and    especially  for 

aortic  regurgitant  murmiirs, 

(6)  The     "ventricular   site"    for    aortic,     for    mitral,    and    for    haemic 

murmurs. 

No  endocardial  murmurs  will  escape  this   search  ,   and  it  is  improbable 
that  any  exocardial  murmurs  could  pass  unobserved. 


THE  AREAS  OF  CONDUCTION   OF   MURMURS. 

The  following  Outlines  are  devoted  to  a  study  of  the  areas  of  conduction 
of  the  cardiac  murmurs.  The  mode  of  conduction  is  characteristic  in  each 
case  ;  in  some  of  the  murmurs  it  is  so  characteristic  that  a  diagnosis  of  the 
variety  of  murmur  present  may  rest  upon  this  feature  alone. 


FIG.  XLIX. 


The  apex-circle — seat  of  the  mitral  murmurs.  The  lower  sternal 
circle — seat  of  the  tricuspid  regurgitant  murmur.  The  circle  at  the  right 
interspace — centre  for  aortic  murmurs.  The  circle  at  the  left  interspace 
— centre  for  pulmonary  murmurs  and  for  Naunyn  and  Balfour's  murmur. 
TA — at  the  mid  sternum,  is  a  common  seat  for  the  regurgitant  aortic  mur- 
mur. •  .  •  and  :  form  part  of  the  "  ventricular  site,"  where  the  regurgitant 
aortic  murmur  is  sometimes  heard,  and  mitral  and  haemic  murmurs  may  also 
be  audible. 


128  CARDIAC   OUTLINES, 


THE   SITE   AND   AREA   OF  CONDUCTION  OF  THE 

SYSTOLIC  PULMONARY  MURMUR,  AND 

OF  THE  H^MIC  MURMUR. 

Putting  aside  cases  of  congenital  disease,  organic  murmurs  of  the  pul- 
monary orifice  are  uncommon  ;  especially  that  of  regurgitation,  which  has 
not  been  included  in  the  Outlines. 

The  characters  of  a  Systolic  (onward  or  obstructive)  Pulmonary  Murmur 
are  : 

Intensity  at  the  site  of  the  Pulmonary  Valve, 

Extension  along  the  left  2d  and  3d  cartilages,  and  the  2d  and  3d  inter- 
spaces, and  towards  the  right  as  far  as  the  right  edge  of  the  sternum. 

Th's  description  applies  also  to  the  haemic  murmur  which  is  often  a  very 
"rough"  sounding  one.  Its  mechanism  is  still  doubtful,  but  most  author- 
ities agree  in  localising  the  production  of  sound  in  the  Pulmonary  Artery. 
This  is  not  the  view  taken  by  the  Naunyn  and  Balfour. 


FIG.   L. 


The  arrow  represents  the  pulmonary  systolic  murmur,  and  the  shading 
its  usual  area  of  conduction. 


129 


130  CARDIAC   OUTLINES. 


OUTLINE  RELATING  TO  NAUNYN  AND  BAL- 
FOUR'S MURMUR. 

Naunyn  and  subsequently  Balfour  failed  to  obtain  proof  of  the  localisa- 
tion just  mentioned.  They  propounded  the  view  that  a  functional  murmur 
was  apt  to  be  produced  by  a  dilatation  of  the  mitral  orifice,  forming  part 
of  a  general  dilatation  of  the  heart,  and  allowing  backward  injection  of  the 
already  full  Left  Auricle. 

The  cross  placed  in  the  Outline  of  the  Left  Auricular  appendix  is  intended 
to  remind  the  student  of  this  important  theory,  a  discussion  of  which  does 
not  belong  to  the  scope  of  these  pages. 


FIG.   LI. 


The  small  cross  draws  attention  to  the  left  auricular  appendix,  which 
is  supposed  to  be  the  seat  of  regurgitation  from  the  left  ventricle. 


131 


132  CARDIAC  OUTLINES. 


THE  SITE  AND  AREA    OF    CONDUCTION    OF  THE 
TRICUSPID  REGURGITANT  MURMUR. 

Tricuspid  incompetence  is  extremely  common;  loudness  of  the  tricuspid 
regurgitant  murmur,  much  less  common.  A  knowledge  of  this  fact  should 
keep  us  on  the  alert  lest  we  should  pass  over  a  murmur  which  was  only  just 
audible. 

The  conditions  which  favour  the  wide  conduction  of  the  mitral  systolic 
murmur  fail  in  this  case  ;  and  the  overlapping  of  the  right  over  the  left 
ventricle  is  a  likely  source  of  confusion  between  the  two  murmurs  and  a 
special  reason  for  care  in  diagnosis. 

WHERE   TO    LISTEN    FOR   THIS    MURMUR. 

As  indicated  by  the  shading,  the  base  of  the  xiphoid  and  the  lower  ex- 
tremity of  the  sternum,  especially  on  the  right  side  of  the  middle  line,  are 
the  sites  of  intensity.  This  is  the  place  for  auscultation,  although  the 
murmur  may  be  conducted  elsewhere  ;  for  a  mitral  murmur  is  probably 
never  conducted  to  this  spot,  whilst  a  tricuspid  murmur  is  always  loudest 
here. 

The  arrow  in  the  Outline  is  not  placed  in  the  direction  of  the  regurgitant 
blood  stream,  but  rather  in  the  direction  of  the  sternal  conduction  of  the 
murmur. 

The  characters  of  a  Tricuspid  Regurgitant  Murmur  are  : 

(i)  Occurrence  at  the  moment  of  the  Ventricular  Systole  ;  (thereby  the  ist 
sound  may  or  may  not  be  completely  replaced.) 

(2)  Blowing  character  (bellows  sound)  ; 

(3)  Intensity  greatest  over  the  xiphoid  cartilage,  and  tip  of  the  sternum  ; 

(4)  The  bruit  is  very  superficial  ("  near  the  ear")  ; 

(5)  It  is  conducted  for  some  distance  upwards  along  the  sternum,   and 

sometimes  to  the  left  of  that  bone. 
N.  B.     A  Direct  (onward)  Tricuspid  Murmur  is  very  uncommon. 


FIG.    LII. 


The  arrow  represents  the  murmur,  although  not  the  direction  of  the 
regurgitant  blood  stream.  The  shading  gives  the  area  of  conduction,  which 
may,  however,  be  more  considerable  than  here  shewn. 


133 


134  CARDIAC   OUTLINES. 

THE  SITE  AND  AREA  OF    CONDUCTION    OF    THE 
ONWARD  AORTIC    MURMUR. 

The  site  of  intensity  extends  in  this  case  above  the  level  of  the  valvular 
orifice,  which  is  rather  deeply  situated  behind  the  3d  left  sternal  junction 
and  adjoining  portion  of  the  sternum.  The  murmur  is  conducted  loudly 
over  the  shaded  surface,  owing  to  the  strength  of  the  ventricular  contraction, 
and  owing  to  the  close  and  extensive  relation  of  the  aortic  arch  and  of  its 
branches  to  the  sternum  and  to  the  upper  costal  cartilages.  Often  the  mur- 
mur is  not  only  locally  a  very  loud  one,  but  it  is  audible  over  a  very  large 
surface,  or  even  over  the  whole  chest.  A  thrill  is  a  frequent  accompaniment 
of  an  extensive  murmur  of  this  kind. 

In  the  Outline  the  shading  has  been  restricted  to  the  area  which  is  usually 
described  as  that  of  conduction  for  aortic  systolic  murmurs,  and  over  which 
the  latter  are  always  audible,  if  audible  at  the  site  of  intensity. 

It  is  an  important  diagnostic  feature  of  this  murmur  that  it  is  loudly  con- 
veyed along  the  carotids.  The  same  is  true  of  a  hcemic  aortic  murmur,  but 
the  general  clinical  features  of  the  case,  as  well  as  the  cardiac  symptoms, 
seldom  allow  any  confusion  between  the  organic  and   the  functional  bruits. 

The  peculiarities  of  sound  special  to  the  aortic  systolic  murmur  vary  ;  it 
may  be  harsh,  blowing,  noisy,  sometimes  musical  and  sometimes  accom- 
panied with  grating  or  knocking  sounds. 

In  conclusion  the  characters  of  the  Onward  Aortic  Murmur  are  : 

(i)  Occurrence  at  the  moment  of  systole  (with  or  without  complete  replace- 
ment of  the  1st  sound)  ; 

(2)  Relatively  long  duration  ; 

(3)  Loudness  ; 

(4)  Superficial  type  ; 

(5)  Variously  harsh,  rumbling,  grating,  or  musical  character  ; 

(6)  Intensity  greatest  over  the  2d  right  cartilage  and  interspace  ; 

(7)  Conduction  chiefly  upwards  to  the  root  of  the  neck  ;  (but  it    may  ex- 

tend over  the  left  upper  pectoral  region,  as  well  as  over  the  right, 
or  even  over  the  whole  front  of  the  chest.) 

(8)  Conduction  along  the  carotid  arteries 

(9)  Very  commonly  a  thrill. 


FIG.   LIII. 


The  arrow  indicates  the  direction  of  the  blood  stream  producing  the 
onward  aortic  murmur.  The  shading  corresponds  with  the  minimum  area 
of  conduction. 


135 


136  CARDIAC  OUTLINES. 


THE  SITE  AND   AREA  OF   CONDUCTION  OF   THE 
REGURGITANT    AORTIC   MURMUR. 

This  bruit  resembles  a  breath  blown  quickly  from  the  throat  without 
approximating  the  lips.  It  has  been  compared  to  the  noise  of  an  escape  of 
steam.     To  put  the  matter  more  precisely  its  peculiarities  are  : 

Evenness, 

High  pitch, 

Softness,  or  breath-like  nature, 

Absence  of  sonorous  vibrations, 
a  combination  not  presented  by  any  other  murmur. 

The  softness  and  slight  intensity  of  this  bruit  call  for  special  attention  in 
searching  for  it.  It  is  of  all  murmurs  the  most  apt  to  be  missed  owing  to  a 
faulty  or  unsuitable  stethoscope  :  a  caution  to  be  laid  to  heart,  not  only  by 
the  student  undergoing  examinations,  but  by  the  practitioner  in  his  more 
responsible  duties. 

WHERE   TO    LISTEN    FOR   THIS    MURMUR. 

Its  site  of  intensity  is  below  the  level  of  the  aortic  valves,  over  the  mid- 
sternum,  and  over  the  sternal  end  of  the  right  4th  cartilage.  It  is  not  com- 
monly louder  beyond  the  sternum  than  over  that  bone,  although  this  some- 
times occurs. 


FIG.  LIV. 


The  direction  of  the  arrow  is  that  of  the  blood  reflux  producing  the 
more  common  form  of  diastolic  aortic  murmur.  The  shading  indicates  the 
three  directions  in  which  the  murmur  may  be  conducted. 


137 


138  CARDIAC  OUTLINES. 


Its  conduction  may  be  over  a  wide  area,  as  shewn  in  the  Outline,  but  more 
often  it  occupies  a  portion  only  of  the  shaded  surface. 

Upwards  :  It  may  extend  as  far  as  the  ist  right  interspace. 

Outwards  :         Conduction  may  take  place  horizontally  towards  the  left. 
Downwards  :     The  murmur  may  extend  as  far  as  the  apex. 

It  has  been  described  as  occasionally  heard  at  the  apex  only.  This  is  the 
exception.  The  rule  is  for  the  murmur  to  be  most  plainly  heard  over  the 
lower  half  of  the  sternum.  Indeed  it  is  practically  as  loud  over  the  lower 
sternal  third  as  higher  ;  and  this  situation  may  be  regarded  as  the  site  of 
election  for  listening  for  the  murmur,  being  alike  remote  from  the  area  of 
the  respiratory  and  from  that  of  the  cardiac  sounds.  Whilst  being  conducted 
by  the  sternum,  the  sound  is  sometimes  perceptibly  modified  by  that  bone. 

The  diversity  in  the  mode  of  conduction  of  aortic  regurgitant  murmuis  's 
ascribed  to  the  fact  that  the  lesion  may  be  limited  to  any  one  of  the  three 
segments,  or  to  two  of  them,  or  may  extend  to  all  three. 

Sir  Walter  B.  Foster  long  since  explained  on  these  lines  the  occasional 
conduction  to  the  apex  of  a  regurgitant  murmur,  the  right  posterior  segment 
being  then  supposed  to  be  at  fault. 

N.  B.  The  danger  of  mistaking  for  an  aortic  murmur  a  diastolic  murmur 
produced  at  the  mitral  orifice  should  be  borne  in  mind. 


CARDIAC  OUTLINES.  1 39 


The  distinctive  features  of  an  Aortic  Regurgitant  Murmur  are  •; 

(i)  Occurrence  at  the  moment  of  the  normal  closure  of  the   Semilunar 

valves  (the  aortic  second  sound  may  or  may  not   be   completely 

replaced)  ; 

(2)  Continuance  of  the  bruit  during  the  first  part  of  the  diastolic  silence, 

M'ith  gradual  subsidence  ; 

(3)  Breath-like  character,  of  various  but  usually  rather  high  pitch  ; 

(4)  Soft  and  distant  character  ; 

(5)  Intensity  greatest  behind  the  sternum,  at  the  level  of  the  second  inter- 

space ; 

(6)  Conduction  chiefly  down  the  sternum  ; 

\'i)  Occasional  conduction  towards  the  left  nipple,  or  towards  the  apex. 

Roughness,  loudness,  musical  character,  and  thrill  are  rarely  present. 


140  CARDIAC  OUTLINES, 


THE  SITE  AND   AREA  OF    CONDUCTION  OF    THE 
REGURGITANT  MITRAL    MURMUR. 

This  is  the  most  common  of  all  organic  valvular  murmurs. 

Its  loudness  and  its  quality  vary  greatly  according  to  the  extent  and  more 
particularly  to  the  variety  of  the  lesion.  It  is  not  breath-like  as  the  aortic 
regurgitant  murmur,  but  blowing  (bellows  sound).  It  may  be  soft  blowing, 
hard  blowing,  rough,  or  even  musical. 

Its  diagnosis  from  exocardial  and  from  haemic  murmurs  is  by  no  means 
always  easy. 

WHERE    TO    LISTEN    FOR   THIS    MURMUR. 

Always  at  the  apex.  But,  inasmuch  as  other  systolic  murmurs  are  also 
audible  here,  careful  discrimination  is  needed. 

The  site  of  intensity  of  the  mitral  systolic  murmur  is  the  apex  :  this  is  not 
the  case  with  the  aortic  systolic  murmur,  nor  with  the  tricuspid,  nor,  as  a  rule, 
with  the  hccmic  murmurs. 

The  conduction  as  shewai  in  the  shaded  part  of  the  Outline  is  outwards 
and  slightly  upwards  towards  the  axilla. 

The  arrow  shews  somewhat  roughly  the  direction  of  the  regurgitant  blood 
stream.  The  murmur  may  also  be  heard  at  the  angle  of  the  left  scapula  and 
to  the  left  of  the  6th  dorsal  vertebra.  The  reason  for  this  is  obvious  when 
we  look  at  a  lateral  view  of  the  heart. 


FIG.    LV. 


The  arrow  shews  the  direction  of  the  blood  reflux.     The  shading  indi- 
cates the 'area  of  conduction  of  the  murmur. 


141 


142  CARDIAC  OUTLINES. 


THE   HEART   VIEWED   FROM   THE   LEFT   SIDE    TO 

ILLUSTRATE  THE  MODE  OF  CONDUCTION  OF 

THE  REGURGITANT  MITRAL  MURMUR. 

The  Outline  is  intended  to  shew  the  extensive  surface  of  the  left  ventricle 
which  presents  in  the  left  half  of  the  chest,  and  transmits  the  murmur  out- 
wards to  the  lateral  wall  of  the  thorax.  The  auricle  into  which  regurgitation 
occurs  is  doubtless  the  channel  for  the  conduction  of  the  murmur  back- 
wards. The  size  of  the  heart  in  this  Outline  is  disproportionate,  but  it  will 
be  remembered  that  hypertrophy  is  among  the  results  of  mitral  in- 
competence. 

Conduction  towards  the  right  also  takes  place,  but  does  not,  as  a  rule, 
extend  much  beyond  the  parasternal  line  ;  although  owing  to  its  loudness  a 
mitral  murmur  may  not  infrequently  be  distantly  audible  beyond  the  latter. 

Tricuspid  regurgitatioji  being  commonly  associated  with  advanced  mitral 
incompetence,  both  murmurs  may  be  blended  at  the  left  parasternal  region. 
Their  simultaneous  existence  will  be  manifest  if  the  systolic  murmur  gains 
in  intensity  towards  the  right  chondro-xiphoid  angle,  whilst  on  the  other 
hand  it  attains  a  maximum  at  the  apex  of  the  heart. 

A  purely  haemic  bruit  will  be  audible  over  the  left  upper  portion  of  the 
prsecordium,  but  almost  invariably  it  will  be  loudest  at  the  2d  left  interspace 
close  to  the  sternum. 

Lastly  an  aortic  systolic  murmur,  which  is  often  propagated  to  the  whole 
praecordium  and  even  beyond  its  limits  will  be  much  more  intense  over  the 
right  2d  interspace  and  cartilage,  and  will  be  conducted  into  the  carotids 
{cf.  p.  134). 


FIG.   LVI. 


Dilated  and  hypertrophied  heart  in  a  child.  The  greater  part  of  the 
convex  surface  of  the  left  ventricle  faces  the  axillary  region.  It  would  the 
more  closely  approach  the  latter  the  greater  the  degree  of  the  cardiac  hyper- 
trophy. The  left  aspect  of  the  left  auricle  is  also  in  view,  but  the  bulk  of  the 
auricle  faces  the  spine. 

143 


144  CARDIAC  OUTLINES. 


THE  SITE  AND  AREA  OF    CONDUCTION    OF    THE 

MITRAL    AURICULAR-SYSTOLIC,    PR.^- 

SYSTOLIC,  OR  DIASTOLIC  MURMUR. 

This  murmur  may  occur  alone  ;  more  commonly  it  is  complicated  with  a 
mitral  systolic  murmur. 

I. 

UNCOMPLICATED  AURICULAR-SYSTOLIC  MURMUR. 

The  Outline  illustrates  the  downward  and  outward  direction  of  the  blood 
stream  in  the  left  ventricle  and  the  thrill  to  which  it  gives  rise  at  the  apex  of 
the  left  ventricle.  The  circle  denotes  the  strict  limitation  of  the  murmur  to 
the  apex  region. 

The  following  are  among  the  chief  characters  of  this  murmur  : 

Inconstancy  in  occurrence  ; 
Variability  in  quality  ; 

Diversity  of  sounds  audible  in  different  cases  (see  below)  ; 
Limitation  to  a  small  region,  at  most  3"  in  diameter,  including  the  apex  ; 
Accompanying  thrill ; 
Forcible  systolic  impulse  of  the  apex  ; 
Abrupt  loudness  of  the  systolic  sound  at  the  apex  ; 
Loudness  of  the  2d  pulmonary  sound  ; 

Absence  of  conduction  towards  the  axilla  and  to  the  back  ; 
Displacement  of  the  apex  outwards  and  slightly  downwards  (as  indicated 
by  the  arrow). 

WHERE   TO    LISTEN    FOR   THIS   MURMUR. 

Auscultation  should  be  made  at  the  apex,  and  preferably  a  little  external 
to  the  usual  apex  site,  for  it  will  be  found  that  the  apex  beat  is  not  limited 
to  a  single  point  but  presents  a  rather  considerable  surface. 


FIG.   LVII. 


The  arrow  indicates  the  direction  of  the  blood  stream  during  the  period 
of  murniur  The  imited  area  over  which  the  murmur  extend?  is  circum- 
scribed by  the  circle.  The  localised  thrill  is  expressed  by  the  waviness  of 
the  head  of  the  arrow. 

145 


146  CARDIAC   OUTLINES. 


The  Three  chief  Varieties  of  auricular-systolic  murmurs  are  : 
(i)  The  early  diastolic  murmur, 

(2)  The  mid-diastolic  murmur, 

(3)  The  late  diastolic,  or  praesystolic  murmur  in  the  strict  sense. 
Additional  varieties  arise  according  as  murmurs  (i)  and  (2)  are,  or  are 

not,  continued  through  the  diastolic  interval. 

A  discussion  of  the  causes  of  these  several  varieties  would  be  at  the  best 
speculative,  and,  for  that  reason  alone,  ill  suited  for  the  scope  of  this  book. 

DIFFERENTIAL    DIAGNOSIS    OF   AURICULAR-SYSTOLIC    MURMURS. 

The  least  equivocal  variety  is  the  mid-diastolic,  when  the  murmur  is  con- 
ducted up  to  a  loud  I  St  sound  and  followed  by  a  loud  pulmonary  2d 
sound.  Confusion  is  most  liable  to  occur  in  the  case  of  the  early  and  in  the 
case  of  the  late  diastolic  (or  praesystolic)  murmur.  The  first  of  these  might 
be  mistaken  for  an  aortic  regurgitant  murmur,  especially  if  (as.recorded  in 
rare  cases)  it  should  be  audible  at  the  apex  only. 

The  late  murmur  might  be  so  closely  followed  by  the  systolic  event  as  to 
suggest  that  it  formed  part  of  the  latter.  In  many  cases  of  this  kind  indi- 
vidual opinion  based  upon  individual  perception  for  sound  and  time  is  the 
ultima  ratio. 

In  both  cases  assistance  will  be  derived  froni  the  presence  or  absence  of 
the  other  physical  signs  of  mitral  stenosis  (described  above)  ;  and  from  the 
presence  or  absence  of  those  belonging  respectively  to  mitral  or  to  aortic 
incompetence.  The  pulse,  which  is  distinctive  in  all  three  conditions,  is  a 
valuable  help. 

And  lastly,  the  symptoms  may  tell  strongly  in  one  or  the  other  direction. 

It  should  not  be  overlooked  : 

(i)  that  all  three  varieties  may  be  imitated  by  exocardial  sounds  ; 

(2)  that  the  prsesystolic  murmur  may  be  closely  imitated  by  the  heaving 
and  delayed  first  sound  of  an  hypertrophied  heart  confined  by  adhesions  ; 

(3)  that  the  auricular-systolic  murmur  may  be  "cogged"  or  "inter- 
rupted "  and  may  thus  be  thought  to  be  a  reduplicated  second  sound. 


CARDIAC   OUTLINES,  147 


II. 

AURICULAR-SYSTOLIC  MURMURS  ASSOCIATED  WITH 
OTHER  MURMURS. 

Very  commonly  a  mitral  diastolic  murmur  is  associated  with  another,  or 
even  with  two  other  murmurs.  The  ordinary  complication  is  that  of  a 
mitral  systolic  murmur  ;  and  this  may  deprive  us  of  a  helpful  sign  for  diag- 
nosis, viz.,  the  snapping  or  knocking  First  Sound.  An  inevitable  compli- 
cation eventually  follows,  viz. ,  backflow  through  a  dilated  tricuspid  ;  unless 
the  latter,  as  sometimes  occurs,  should  have  become  secondarily  stenosed. 
The  dilated  tricuspid  orifice  will  give  rise  to  a  murmur  ;  but  tricuspid  steno- 
sis will  seldom  be  sufficiently  complete  to  give  rise  to  an  audible  bruit. 

Aortic  valvular  disease  is  a  complication  by  no  means  rare. 

Pericardial  friction  has  already  been  mentioned. 

Lastly,  when  cardiac  failure  has  supervened  the  cardiac  rhythm  may 
audibly  suffer  from  the  strain,  and  loud  reduplication  of  one  of  the  sounds  is 
the  result.  The  confusing  whirl  of  cardiac  sounds  thus  produced  has  been 
termed  by  the  French  "bruit  de  galop"  :  the  heart's  rate  is  usually  very 
high  under  these  circumstances,  and  all  distinctive  murmurs  may  for  a  time 
be  submerged. 

Short  of  the  climax  of  confusion  just  described  any  superadded  murmur 
will  be  a  serious  obstacle  to  strict  definition  of  this  bruit  by  auscultation. 
There  is,  however,  in  stenosis  a  peculiarity  of  the  heart's  action  as  a  whole, 
which  seldom  misleads  the  experienced  ear,  though  individual  sounds  may 
be  too  rapid  for  due  appreciation. 


148  ^      CARDIAC  OUTLINES, 


THE  AUSCULTATORY  SIGNS  OF  CARDIAC 
HYPERTROPHY. 

No  bruits  are  connected  with  hypertrophy  pure  and  simple.  At  most  the 
normal  sounds  are  more  or  less  moditied  (see  p.  116).  The  first  sound  is 
exaggerated,  ponderous,  prolonged,  and  heaving  ;  the  second  sound,  more  or 
less  accentuated.  A  reduplication  of  the  first  sound,  heard  near  the  apex, 
has  been  pointed  out  by  Dr.  Broadbent  as  a  sign  of  albuminuria,  and  will 
often  be  found  in  cases  of  renal  hypertrophy  of  the  left  ventricle. 

The  cardiac  rhythm,  if  altered,  is  slowed  rather  than  accelerated.  None 
of  these  signs,  however,  belong  to  hypertrophy  exclusively.  Palpation  and 
percussion  must  be  called  to  aid  for  its  diagnosis,  which  is  often  also  much 
assisted  by  the  general  symptoms. 


CARDIAC   OUTLINES,  1 49 


THE    AUSCULTATORY    SIGNS    OF    CARDIAC 
DILATATION. 

There  are  no  bruits  distinctive  of  cardiac  dilatation  per  se,  although 
symptoms  arising  from  the  associated  valvular  incompetence  are  usually 
present. 

On  the  other  hand,  the  normal  action  and  sounds  are  decidedly  altered. 

(i)  The  rhythm  is  accelerated  and  may  be  irregular  ; 

(2)  The  ventricular  impulse,  although  unduly  prominent  and  (except 
in  cases  where  dilatation  is  due  to  pre-existing  pulmonary  emphysema)  very 
extensive,  lacks  the  hard  feel  of  the  hypertrophied  ventricle  ; 

(3)  The  1st  heart-sound  is  feeble,  short,  and  sometimes  faltering.  The 
shortness  of  the  ist  sound  arises  from  the  spasmodic  effort  of  the  overtaxed 
ventricle,  which  endeavours  in  vain  to  empty  itself  completely  ; 

(4)  The  weakness  of  the  second  sound  is  connected  with  the  low  pressure 
under  which  the  aorta  is  injected  ; 

(5)  The  overcharged  ventricle  hastens  to  contract  again  :  the  long 
pause  is  thereby  shortened  ; 

(6)  A  frequent  result  is  an  apparent  equality  of  the  1st  and  of  the  2d 
sound  as  regards  strength  and  quality,  and  of  the  ist  and  2d  pause  as 
regards  duration  ; 

This  resemblance  with  the  foetal  heart's  action  (embryocardia)  is  strength- 
ened by  the  rapidity  of  rate  which  the  dilated  heart  has  in  common  with 
the  foetal. 

(This  description  applies  to  cases  of  considerable  dilatation  affecting  the 
whole  heait ;  it  would  have  to  be  modified  in  cases  where  the  dilatation 
was  unilateral  or  complicated  with  hypertrophy.) 


I50  CARDIAC  OUTLINES. 

AORTIC    ANEURYSM. 

THE  STRUCTURES  LIABLE  TO  IMPLICATION  IN  ANEURYSM 
OF  THE  ASCENDING  AORTA  AND  OF   THE  ARCH. 

Aortic  Aneurysm  is  a  very  large  subject,  rendered  all  the  more  difficult  to 
treat  owing  to  the  diversity  of  individual  cases.  A  systematic  account  of 
the  whole  is  not  therefore  attempted.  The  accompanying  Outline  has 
regard  only  to  the  important  anatomical  questions  which  have  to  be  consid- 
ered in  all  cases  of  aneurysm  of  the  arch  or  of  the  ascending  aorta.  It  has 
for  its  purpose  to  help  the  student  to  realise  the  mechanical  results  of  the 
growth  of  tumours  of  this  sort. 

Leaving  aside  the  intracardiac  aneurysms  and  aneurysms  situated  just 
above  the  valves,  the  pressure  from  which  takes  effect  upon  the  substance 
or  the  cavities  of  the  heart,  we  shall  consider  only  those  whose  growth 
is  well  above  the  sinuses  of  Valsalva. 

A  feature  of  all  aneurysms  of  this  class  is  that  the  aortic  cd  sound  is 
"  thudding,"  i.e.,  very  loud  and  very  much  accentuated.  The  large  symbol 
A  has  reference  to  this  fact. 

The  Vena  Cava  Superior,  although  a  most  important  structure  in  relation 
to  aneurysm  of  the  first  part  of  the  aorta,  could  not  be  introduced  into  the 
diagram  ;   it  should  have  occupied  the  site  of  the  symbol  A* 

PRESSURE    EFFECTS. 

In  aneurysm  of  the  1st  portion  pressure  is  apt  to  bear  : 
(r)  forwards — on  the  anterior  chest-wall,  etc. 

(2)  to  the  right — on  the  Superior  Vena  Cava,  and  on  the  lung. 

(3)  backwards — on  the  right  bronchus,  or  trachea  ;   and  on  the  right 

pulmonary  artery. 
In  aneurysm  of  the  Arch  pressure  tells  : 

(i)  downwards  and  backwards — on  the  left  bronchus,  or  on  the  trachea  ; 
on  the  left,  or  on  the  right  pulmonary  artery  ;  and  on  the  left 
recurrent  laryngeal  nerve. 

(2)  forwards  and  upwards — on  the  left  Innominate  Vein. 

(3)  to  the  left — on  the  upper  part  of  the  left  lung. 

Dyspnoea  may  thus  result  either  from  direct  compression  and  finally 
ulceration  of  the  left  bronchus  or  trachea,  or  indirectly  owing  to  stretching 
of  the  left  recurrent  laryngeal  nerve. 


FIG.   LVIII. 


A— Arch  of  the  aorta.  P— Pulmonary  artery.  R— Left  recurrent 
laryngeal  nerve,  in  contact  with  the  aortic  end  of  the  ductus  arteriosus. 
A — Site  of  loud  thudding  aortic  second  sound. 

^  N  B  —  The  superior  vena  cava  should  have  been  shewn  along  the  right 
side  of  the  ascending  aorta.  The  trachea  afid  main  bronchi,  ^^jj J^^^  ^^^^^^, 
strucitires,  will  be  easily  recognised.      The  arrows  indicate  the  middle  line. 

151 


152  CARDIAC  OUTLINES, 

PERICARDITIS. 


A  BRIEF  SUMMARY  OF  ITS  VARIETIES  AND 
TYPICAL  SIGNS. 

I. 

LOCAL  OR   LIMITED  PERICARDITIS. 

The  affection  is  generally  not  severe  ;  commonly  it  remains  latent  and  is 
not  diagnosed.      It  results  in  : 

Adhesion,  or 
Roughening  of  surfaces. 

LIMITED    PERICARDIAL    ADHESIONS, 

These  are  often  not  capable  of  recognition  during  life. 
Clinically  they  are  not  regarded  as  of  serious  import. 

LIMITED     PERICARDIAL    ROUGHNESS. 

(i)   This  may  be  known  by  the  occurrence  of  friction  sounds  over  a  limited 
area. 

(2)  During  its  earlier  stage  it  may  give  rise  at  first  to  a  softer  variety  of 

sound,  the  "  pericardial  (or  exocardial)  murmur." 

(3)  The  roughness  ultimately  disappears,  leaving  only  a  smooth,  thick- 

ened, or  opaque  patch  on  the  pericardial  membrane  ;  this  is  one 
form  of  the  "  white-patch  "  or  "  milk-spot." 

II. 

GENERAL  PERICARDITIS. 

(a)    SIMPLE   OR    UNCOMPLICATED    GENERAL    PERICARDITIS. 

Of  this  there  are  two  varieties  : 

Dry  or  fibrinous  pericarditis. 
Pericarditis  with  effusion. 


CARDIA C  OU TLINE S.  1 5 3 

(b)  general  pericarditis  of  complicated  or  of  specific  type. 

Pericarditis  may  be  the  result  of  specific  causes  such  as  : 

Pyaemia, 

Tuberculosis, 

Carcinoma,  etc. 
These  forms  of  the  disease  may  or  may  not  follow  a  course,  and  give  rise 
to  signs  analogous  to  those  of  the  simple  variety. 

DRY  OR   FIBRINOUS   PERICARDITIS. 

This  may  be,  as  previously  stated,  only  a  stage  in  pericarditis  ;  or  it  may 
constitute  the  whole  disease.  The  fibrin  thrown  out  at  the  surface  of  the 
membrane  leads  to  one  of  two  results  : 

(a)  Pericardial  agglutination  or  adhesion  ;  or 

(b)  Pericardial  friction  and  attrition. 

(a)  pericardial  agglutination  or  adhesion. 

Adhesions  may  arise  : 

(i)  Between  the  heart  and  its  sac  {intra-pericardial  adhesions)  ;  or 

(2)  Between  the  pleuro-pericardium,  or  lateral  layer  of  the  sac,  on  the  one 

hand,  and  the  chest-wall  or  the  median  surface  of  the  lung  on  the 
other  (extra-pericardial  adhesions)  ;  or,  lastly, 

(3)  Between   all    these    structures   simultaneously,    the    heart   becoming 

adherent  to  its  sac,   and  the  sac  to  its  surroundings  (intra-  and 

extra-pe7-icardial  adhesions). 
Pericardial  adhesions  vary  in  their  consistence  and  in  their  length,  and 
therefore  in  their  effect  upon  the  heart.      Pericardial  agglutination  implies 
an  absolute  fusion  between  the  opposed  layers  of  the  serous  membrane. 

(b)  pericardial  friction  and  attrition. 

Friction  is  the  mechanical  result  of  the  heart's  movements  in  contact  with 
a  roughened  membrane.  It  occurs  at  the  first  stage  of  every  pericarditis, 
whether  subsequently  adhesive,  attritive,  or  exudative.  Continuous  friction 
will  wear  itself  out  after  varying  periods,  the  pericardial  surface  becoming 
once  more  polished.  So  long  as  roughness  of  the  surface  persists  it  is  apt 
to  give  rise  to  audible  friction-sounds. 


154  CARDIAC   OUTLINES. 

FRICTION  SOUNDS  AND   FRICTION  MURMURS. 

Pericardial  friction  may  be  : 

(a)  External,  or 

(b)  Internal,  to  the  sac. 

(a)  EXTERNAL    PERICARDIAL    FRICTION    SOUND. 

By  this  is  meant  the  friction  sound  set  up  by  the  heart's  action  between 
an  inflamed  pleuro-pericardial  membrane  and  an  inflamed  pleural  surface 
(be  it  parietal  or  visceral),  the  inner  surface  of  the  pericardial  sac  remain- 
ing unaffected.  This  friction  is  always  difficult  to  tell  from  internal  peri- 
cardial friction. 

When  it  occurs  over  the  anterior,  or  subchondral,  surface  of  the  pleuro- 
pericardial  fold  its  locality  is  rather  more  easily  traced, 

(i)  because  in  that  situation  friction  due  to  respiratory  movement  is 
plainly  audible  in  the  interval  between  the  heart-beats  ;  and 

(2)  because  friction  due  to  the  movements  of  the  heart  is  markedly  dimin- 
ished when  the  chest  is  kept  at  rest  in  the  position  of  full 
inspiration. 

When,  however,  friction  is  limited  to  the  lateral,  deep,  or  pulmonary 
surface  of  the  pi  euro-pericardium,  the  tests  given  above  may  not  be  so 
effectual  ;  and  the  distant  rubbing  sound,  being  conducted  through  the 
heart's  substance  to  the  praecordium,  may  appear  to  be  independent  of  any 
pleural  origin  or  influence. 

(b)  INTERNAL   PERICARDIAL    FRICTION    SOUNDS. 

These  are  the  sounds  special  to  pericarditis  properly  so  called.  We  may 
study  with  profit  : 

Their  audible  characters, 
Their  site. 
Their  rhythm. 

(a)    Their  Audible  Characters. 

Superficial  character  is  special  to  the  group  ;  but  the  ear  distinguishes  a 
coarse  and  a  fine  quality  of  friction.      Moreover,  the  peculiarities  of  the 


CARDIAC   OUTLINES. 


155 


sound  vary  much  in  different  cases,  and  various  names  are  used  to  express 
these  varieties.     The  names  may  be  arranged  in  the  two  following  groups  : 

'^  "  Coarse  rub"  ; 


Fine 
or 

Soft 
Friction 
Sounds : 


^  "Soft  rub"  ; 
"  scratching"  ; 
"  grazing  " 
"  rustling  "  ; 
"  blowing,"  or  "  pericar- 
dial friction-murmur." 


"  creaking,  or 
Coarse  new-leather  sound  "  ; 

or  J    "  churning"  ; 

Rough      1    "  cog-wheel  sound"  ; 
Friction  "  grating  "  ; 

Sounds  :         "  scraping"  ; 
^   "  sawing"; 
An  undulation  in  the  intensity  of  the  sound,  as  though  this  were  advan- 
cing and  receding,  is  very  characteristic  of  pericardial  friction.     It  is  due 
to  the  influence  of  the  respiratory  variations  in  the  size  of  the  lungs. 

(b)    Their  Site. 

Intra-pericardial  friction  sounds  are  by  nature  : 

Localised  ; 

Not  carried  along  the  great  vessels  ; 

Influenced  by  local  pressure  ; 

Not  suppressed  by  holding  the  breath. 
A  very  common  seat  for  the  earliest  indications  of  friction  is  the  mid- 
sternal  or  basic  region  of  the  heart.  The  sound  in  this  case  is  not  con- 
ducted over  the  whole  proecoi'dium  from  the  part  implicated.  Similarly  in 
general  pericarditis  friction  is  not  heard  beyond  the  prsecordium.  Pressure, 
locally  applied,  intensifies  the  friction. 

(c)    Their  Rhythm., 

The  Rhythm  may  be  of  three  kinds  : 

Single, 
Double,  or 
Three-timed. 

(i)  A  single  rub  is  occasionally  heard.  Further  pressure  from  the  stetho- 
scope will  in  most  of  these  cases  set  up  a  double  sound,  although 
sometimes  the  friction  remains  single. 


156  CARDIAC  OUTLINES. 

(2)  The  sound  commonly  described  as  special  to  pericardial  friction,  is 

the  "  to-and-fro  "or  "  see-saw  "  sound. 

(3)  The  truly  typical  "  three-time,"  or  "  cantering,"  sound  will  be  heard 

in  most  cases,  if  carefully  listened  for.  It  is  apparently  due  to 
the  successive  movements  accompanying  the  auricular  systole,  the 
ventricular  systole,  and  the  ventricular  diastole. 

PERICARDITIS  WITH   EFFUSION. 

In  this  form  of  the  disease  there  are  two  stages  : 

The  stage  of  dry  inflammatory  fibrinous  exudation  ; 
The  stage  of  fluid  effusion. 

The  duration  of  the  first  stage  varies  ;  it  is  usually  short.  The  fluid 
effused  during  the  second  stage  may  be 

serous, 

sero-purulent,  or 
purulent. 

The  effusion  may  be  rapidly  fatal  ;  or  toleration  may  be  established,  and 
the  accumulation  may  gradually  assume  considerable  proportions.  The 
subsequent  history  of  pericardial  effusion  belongs  to  clinical  medicine. 

It  is  noteworthy  that  pericardial  friction  does  not  in  all  cases  cease  to  be 
perceived  after  the  occurrence  of  effusion.  The  persistence  of  friction  is 
probably  connected  with  the  position  assumed  by  the  heart  as  a  result  of 
the  distension  of  its  serous  sac.  Fig.  LIX.  illustrates  the  tendency  of  the 
heart  to  become  more  median  in  position  at  the  same  time  as  its  apex  is 
lowered. 

"  Dropsy  of  the  Pericardium," 

"  Hydrops  Pericardii," 

"  Hydro-pericardium  " 

are  equivalent  terms.      If  used  without  further  qualification,  they  convey 
the  idea  of  "  passive  effusion"  (a  more  explicit  and  preferable  synonym). 

A  passive  effusion  may  be  in  its  onset  acute  or  chronic.  Therefore, 
unless  when  specially  stated,  neither  "Pericardial  dropsy"  nor  "Hydrops 
pericardii  "  nor  "  Hydro-pericardium"  imply  the  existence  of  acute  peri- 
carditis. 


FIG.   LIX. 


Changes  in  the  axis  and  in  the  level  of  the  heart  in  pericardial  effusion. 
DD'  the  diaphragm,  and  HH'  the  liver  depressed  to  the  level  of  the  tip  of  the 
xiphoid.  The  cardiaQ  apex  is  lowered  and  brought  nearer  the  middle  lin^ 
than  nornaal, 

J57 


158  CARDIAC   OUTLINES. 

PRACTICAL     POINTS     IN     THE     AUSCULTATORY 
DIAGNOSIS    OF   PERICARDITIS. 

In   all   cases   of    audible   pericardial    friction    two    questions    must  be 
considered  : 

(i)  Is  the  sound  endocardial  or  exocardial? 

(2)  If  not  endocardial,  is  the  sound  due  to  internal  pericarditis  or  to  ex- 
ternal pericarditis  (pleuro-pericarditis)  ? 


DIAGNOSIS    BETWEEN    ENDOCARDIAL    AND    EXOCARDIAL  MURMURS. 

Sometimes  the  sound  of  pericardial  friction  closely  resembles  a  blowing 
sound.  This  variety  of  friction  sound  has  been  described  as  a  "  Friction 
Murmur,"  or  "  Exocardial  Murmur,"  in  contradistinction  with  the  endo- 
cardial or  true  heart-murmurs.  Owing  to  this  similarity  diagnosis  is  often 
very  difficult.  Attention  to  the  following  points  may  be  of  service  in  deter- 
mining the  nature  of  the  doubtful  sound. 

(i)  Since  friction  frequently  results  from  a  limited  roughness,  the  locality, 
if  it  should  happen  to  be  one  unlikely  for  an  endocardial  murmur, 
may  help  the  diagnosis. 

(2)  The  conduction  of  endocardial  murmurs  takes  place  in  definite  direc- 

tions, and  in  the  case  of  some  of  them,  along  the  great  vessels. 
In  pericardial  disease  diffusion  of  the  sound  either  does  not 
occur  or  it  does  not  follow  the  directions  special  to  valvular 
murmurs. 

(3)  The  time  at  which  the  exocardial  murmurs  are  heard  does  not  occupy 

the  same  relation  to  the  time  of  the  normal  heart-sounds  as  would 
belong  to  the  endocardial  murmurs. 

(4)  If  the  pressure  of  the  stethoscope  be  increased,  an  endocardial  mur- 

mur would  probaby  not  be  altered  ;  whereas  a  marked  increase 
may  be  observed  in  the  loudness  of  an  exocardial  murmur. 

(5)  Lastly,   if   the  patient's  posture  be  changed,   an  exocardial  murmur 

would  be  more  apt  to  change  than  an  endocardial  murmur,  although 
posture  frequently  modifies  the  intensity  of  a  cardiac  bruit. 


'    .'•  CARDIAC  OUTLINES.  1 59 

II. 

DIAGNOSIS    BETWEEN     INTERNAL    AND    EXTERNAL     PERICARDIAL     FRICTION 

SOUNDS. 

Does  the  rough  layer  of  fibrin,  conveying  friction  sound  to  the  ear  or 
thrill  to  the  hand,  line  the  pericardial  sac  ;  or  does  it  line  the  pleural  cavity, 
where  the  latter  overlies  the  heart  ? 

(1)  A  conclusive  answer  may  be  obtained  by  interrupting  the  movements 

of  respiration.  If  the  sound  should  cease  as  soon  as  the  breath  is 
stopped,  this  will  clear  up  all  doubt.  If,  however,  friction  should 
persist,  its  source  is  still  open  to  question  ;  for  an  uncomplicated 
external  pericarditis  may  occasion  a  rub  synchronous  with  the 
heart's  action  and  independent  of  any  respiratory  movement, 
although  produced  within  the  pleura. 

(2)  If  the  rhythm  be  distinctly  cantering,   and  the  sound  made  up  of 

auricular  systolic,  ventricular  systolic,  and  diastolic  rubs,  the  seat 
is  almost  certainly  intrapericardial. 

(3)  In    the    absence   of  the  typical  cantering  sound,   diagnosis  may  be 

assisted  by  modifications  of  the  sound  which  may  arise  when  the 
breath  is  held,  whether  in  inspiration  or  in  expiration,  and  especially 
by  those  which  may  be  brought  about  by  exaggerated  respiratory 
movements. 
In  a  proportion  of  cases  the  diagnosis  cannot  be  made  by  unaided 
auscultation. 


PART  VI. 

PRACTICAL    ILLUSTRATIONS    OF     THE    METHOD 
OF    USING  DIAGRAMS  AND  SYMBOLS  FOR 
THE  RECORD  OF  PHYSICAL  EXAMINA- 
TIONS   OF    THE  HEART. 

ON  THE  VALUE  OF  NEGATIVE  NOTES. 

The  value  of  negative  notes  of  symptoms  and  physical  signs  is  appreciated 
by  all  clinical  workers  of  experience.  It  is  not  enough  to  have  ascertained 
the  absence  of  a  physical  sign  ;  the  fact  must  be  recorded  at  the  time,  or  it 
is  lost  to  the  reader  of  the  notes,  and  may  ultimately  be  forgotten  by  the 
observer  himself. 

The  excellence  of  negative  notes  varies  with  the  degree  in  which  they 
are  circumstantial.  A  typical  negative  note  addresses  itself  to  a  single 
and  definite  fact.  Notes  such  as  "  heart  healthy  "  or  "  no  cardiac  murmur" 
may  be  described  as  "  collective"  negative  notes.  They  arc  valuable,  but 
their  value  is  inferior  to  that  of  the  circumstantial  note,  in  which  may  be 
traced  each  separate  examination  tending  towards  the  collective  result.  The 
best  note  is  that  which  bears  evidence  that  each  valve  has  been  examined 
and  found  healthy.  A  note  such  as  the  following  : 
"  Heart  examined  : 

no  onward  or  regurgitant  aortic  murmur  ; 

no  onward  or  regurgitant  mitral  murmur  ; 

no  onward  or  regurgitant  tricuspid  murmur  ; 

no  onward  or  regurgitant  pulmonary  murmur," 

carries  conviction  as  a  statement  of  fact,   but  would  be  a   serious  addition 
to  the  labour  of  each  examination. 

i6o 


FIG.    LX. 


THE    PREPARED     CLINICAL    OUTLINE   BEFORE    USE. 

The  arrows  represent  the  valvular  murmurs  (two  of  which  have  been 
omitted  as  rare).  The  cross  refers  to  Naunyn  and  Balfour's  murmur,  7'Ae 
arroivs  are  to  be  struck  out  if  the  vmrniurs  be  absent.  The  heart  sounds  are 
supp-osed  to  be  normal  ;  if  otherwise,  their  loudness,  or  reduplication,  etc., 
may  be  expressed  by  symbols.  The  heart  boundaries,  depicted  as  normal,' 
may  need  to  be  altered  ii^  accordance  with  the  results  of  percussion. 


1 62  CARDIAC  OUTLINES. 

The  graphic  method  supplies  us  with  an  easy  method  of  fulfilling  the 
indication  without  any  unfair  tax  on  the  observer's  pen. 

THE  PREPARED   CLINICAL  OUTLINE. 

If  a  suitable  diagram  bearing  the  symbols  of  all  the  likely  murmurs  be 
used  in  recoiding  each  physical  examination,  the  absence  of  each  murmur, 
as  soon  as  ascertained  by  examination,  could  be  recorded  by  striking  out 
the  corresponding  symbol,  which,  in  the  case  of  a  murmur  found  to  be 
present,  would  be  allowed  to  stand.  Negative  notes  thus  taken  would  be 
circumstantial,  yet  they  would  occupy  neither  much  lime  nor  much  space,  the 
diagram  remaining  available  for  any  additional  graphic  or  other  note  bearing 
upon  the  percussion  of  the  heart,  or  the  quality  of  the  heart  sounds,  or  tlie 
extent  of  the  area  of  conduction  of  any  murmurs  present,  etc. 

Whilst  it  contributes  to  the  rapidity  and  to  the  definiteness  of  negative 
notes,  the  Prepared  Clinical  Outline  promotes  systematic  examinations, 
and  serves  to  remind  us  of  the  various  points  for  investigation.  This 
feature  renders  this  method  of  notation  specially  useful  for  the  student  who 
has  to  acquire  the  habit  of  completeness  in  cardiac  examination,  and  also 
to  the  busy  practitioner  and  to  the  investigator  who  should  not  depart 
from  it. 

To  the  practitioner  and  to  the  special  worker  alike  the  use  of  serial 
graphic  records  is  a  great  help  in  difficult  and  complex  observations  such  as 
cardiac  disease  necessitates.  A  repetition  of  the  same  chart  for  each  suc- 
cessive examination  permits  progressive  changes  to  be  accurately  followed 
and  sudden  changes  to  be  timed  with  precision. 

Let  us  take  as  an  instance  a  case  of  Rheumatic  Fever  with  threatened 
endocarditis,  in  which  freedom  from  any  valvular  murmur  had  existed  until 
a  given  day,  when  a  murmur  was  first  plainly  heard.  The  use  of  the 
diagram,  as  part,  as  it  were,  of  each  physical  examination,  would  have 
ensured  a  faithful  daily  entry  of  the  hitherto  negative  results,  and  the  case 
would  stand  as  a  complete  and  ready  record  of  the  cardiac  events. 

In  most  rheumatic  cases,  however,  and  in  others  also,  the  change  is 
usually  not  an  abrupt  one.  The  heart-sounds  will  have  altered  their 
character  before  being  replaced  by  murmurs,  and  the  change  will  probably 
have  first  l^een  observed  over  definite  areas  of  the  prascordium  ;  again  the 
rhythm  of  the  sounds  may  have  undergone  some  alteration  ;  and  the  dulness 


FIG.    LXI. 


THE   PREPARED   CLINICAL   OUTLINE    IN    USE. 


All  the  arrows  having  been  struck  out,  the  heart  is  shewn  to  be  free 
from  murmurs.  The  large  symbol  in  the  right  second  interspace  indicates 
considerable  loudness  of  the  aortic  sound.  The  smaller  symbol  in  the  left 
second  interspace  means  that  a  reduplication  is  heard  at  the  site  of  the 
pulmonary  second  sound. 


FIG.    LXII. 


THE   PREPARED    CLINICAL    OUTLINE    IN    USE. 


Five  arrows  having  been  struck  out,  as  well  as  the  cross,  the  correspond- 
ing murmurs  are  absent.  One  arrow  remains,  that  which  represents  the 
systolic  pulmonary  murmur.  The  Outline  does  not  shew  whether  the 
murmur  was  thought  to  be  functional  or  organic.  A  note  stating  the 
observer's  opinion  should  have  been  added  to  the  record. 


.  '.'.  CARDIAC  OUTLINES.  1 65 

may  have  increased  towards  the  left  or  towards  the  right.  A  graphic  nota- 
tion of  facts  of  this  kind  will  not  be  accurate  and  intelligible  unless  fair 
space  be  allotted  to  it.  This  is  the  reason  for  the  size  of  the  Outline 
which  otherwise  might  have  been  thought  inconveniently  large.  Size  is 
specially  important  in  recording  the  relations  of  the  heart  to  the  ribs  and 
interspaces,  and  its  comparative  dimensions  as  found  by  percussion. 

Whenever  accuracy  and  completeness  of  the  record  are  not  essential,  or 
when  a  single  object,  be  it  a  murmur,  an  abnormal  sound,  an  abnormal 
impulse  or  an  abnormal  dulness,  merely  requires  to  be  noted,  the  Elementary 
Clinical  Outline,  Fig.  I.,  will  be  found  easy  to  work  with  in  proportion  to 
its  simplicity. 

Reverting  to  the  Prepared  Clinical  Outline,  we  see  in  Fig.  LXI.  an  illus- 
tration  of  its  application  to  the  recording  of  the  absence  of  murmurs.  Fig. 
LXII.  shews  a  positive  record  of  a  murmur,  whilst  other  murmurs  are 
shewn  to  be  absent.  Lastly  the  use  which  may  be  made  of  the  symbols  for 
heart-sounds  is  illustrated  in  Fig.  LXI. 


THE  END. 


V. 


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